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 THE 
 
 Q^£ f:t-*/^V ^'^^^ - 
 
 PATHOLOGY AND TREATMENT 
 
 DISEASES OF THE OVARIES 
 
 (Being the Hastings Essay for 1873) 
 
 LAWSON TAIT, F.RC.S., Edin. and Eng., 
 
 Surgeon to the Birmlnghmn HosipUal for Women, and Consulting Surgeon (for Diseases of 
 Women) to the West Broniwich Hospital ; Fellow of the Royal Medico-Chirurgical 
 Society ; Member of the Surgical Society of Ireland and of the Medico- 
 Chirurgical Society of Edinburgh, etc., etc. 
 
 HONORAKT FELLOW OF THE AMERICAN GYNECOLOGICAL SOCIETY. 
 
 £o\\x\.\\ ®bition, Ee-roritten anb (BJrcatIn (Enlargeb 
 
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 WILLIAM WOOD & COMPANY 
 
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 1883
 
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 WILLIAM WOOD & COMPANY 
 
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 Printing and Bookbinding Company 
 
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 Dear Dr. MARION SIMS, 
 J tHebitate 
 
 THIS VOLUIVIE TO TOTJ AS A TOKEN OF THE VALTJE I PLACE UPON YOUK 
 
 FKIENDSHIP, AND AS AN ACKNOWLEDGMENT 
 
 THAT MUCH OF THE NEW WOKK DESCKIBED IN IT IS THE OUTCOME OF YOUK 
 
 INGENUITY. 
 
 YouBS Truly, 
 
 LAWSON TAIT.
 
 PREFACE TO THE FOURTH EDITION. 
 
 Since the first edition of this book appeared in 1873, my experience 
 of the subjects it deals with has greatly increased, and necessarily the 
 present work has grown in size. 
 
 I have found reason to change my opinion on some points, but they 
 are of much less importance than I thought they would be when I first 
 sat down to write these pages. I have seen far more reason for ex- 
 tending what I had to say ; for the marvellous success which now at- 
 tends the efforts of those who practise abdominal surgery has fallen 
 largely to raj lot, and therefore records of things accomplished, and 
 opinions expressed upon them, will be found in these pages, which, 
 eight years ago, were certainly beyond the limits of acceptance. Since 
 then, however, great advances have been made, but much yet remains 
 to be done, and all must rest upon the patience of the workers and the 
 forbearance of their critics. 
 
 For many imperfections of my book I have to offer the apology 
 that I have but scant leisure for research, and fear I may not have 
 done justice, in many instances, to the work of others. My writing is 
 chiefly the outcome of my own experience, and of necessity is freely 
 and unavoidably scattered with the pronoun of the first person. 
 
 To avoid needless and cumbersome reference notes, I have given, 
 at the head of each chapter, a list of works which I have consulted on 
 the subjects dealt with. 
 
 LAWSON TAIT. 
 
 Birmingham, October 3. 1882.
 
 CONTENTS. 
 
 CHAPTER I. 
 
 PAQE 
 
 Anatomy and Physiology of the Ovaky and Oviduct, . , , , 1 
 
 CHAPTEE II. 
 
 Ebkoks op Development and Displacements op the Ovakies and Ovi- 
 ducts : Salpingitis, Hydrosalpinx, Pyo-salpinx, HiEJiATO-SALPiNX, 
 and Fallopian Pregnancy, 35 
 
 CHAPTEE III. 
 
 Oophoeitis and Peki-oophokitis — CiKEHOsis op the Ovaky — Abscess op 
 THE Ovaky, ,87 
 
 CHAPTEE IV. 
 
 OVAKIAN TUMOKS AND CONDITIONS "WHICH SIMULATE ThEM, .... 131 
 
 CHAPTEE V. 
 Ovakiotomy, 232 
 
 CHAPTEE VI. 
 Eecent Extensions op Abdominal and Pelvic Sukgeey, .... 322 
 
 Cholecystotomy, 335 
 
 Hepatotomy, 338 
 
 The Treatment of Pelvic Suppuration by Abdominal Section and 
 Drainage, SH 
 
 Index, 353
 
 LIST OF ILLUSTRATIONS. 
 
 FIG. PAGE 
 
 1. Front View of Left Broad Ligament, 5 
 
 2. Diagrammatic Section of Broad Ligament, (5 
 
 3. Dissection of the Vena Cava (Brinton) , 8 
 
 4. Posterior View of Oviduct and Parovarium, .13 
 
 5. Wolffian Body and Ovary of Embryo, 12 
 
 6. Foetal Section showing Development of Ovary, .15 
 
 7. Section of Fcetal Ovary, l(j 
 
 8. Primitive Ova, 17 
 
 9. Germinal Epithelium, 17 
 
 10. Follicular Epithelium, 18 
 
 11. Epithelial Nest, 18 
 
 12. Development of Primitive Ova, . . . 19 
 
 1;>. Section of Ovary at Third Month 19 
 
 14. Section of Ovary at Sixth Month, 20 
 
 15. Obsolescence of Follicles, 22 
 
 16. Ovary at Menopause, 33 
 
 17. Senile Ovary, 33 
 
 18. Tait's Wedge Pessary, 44 
 
 19. Bilateral Hydrosalpinx, 59 
 
 20. Occluded and Adherent Fallopian Tubes, ....... 60 
 
 21. Right and Left Fallopian Tubes and Ovaries, 60 
 
 23. Fatal Case of Ruptured Fallopian Tuba, 78 
 
 23. Posterior View of Same, 78 
 
 24. Exanthematic Cirrhosis of Ovary, 107 
 
 25. Microscopic Section of Same, . 108 
 
 20, Altered Epithelium from Ovarian Cysts, . . . . . . .145 
 
 27. Myxoma of Ovary, 153 
 
 28. Rokitansky's Tumor of the Ovary, 174 
 
 29. ■ Tait's Trocar for Paracentesis Abdominis, 203 
 
 30. Tait's Modification of Koeberle's Forceps, 258 
 
 3L Tait's Trocar for Ovariotomy, . , . „ 261 
 
 32. Tait's Ether Apparatus, 267 
 
 33. Tait's Wire Clamp, 285 
 
 34. Tait's Staffordshire Knot, 287 
 
 35. Double-hitch Knot, 291 
 
 Plate showing Resemblance between Foetal Structure and Cancerous Growth of 
 
 Ovary, 147
 
 ^■-
 
 THE PATHOLOGY AND TREATMENT 
 
 OF 
 
 DISEASES OF THE OVARIES. 
 
 CHAPTER I. 
 
 ANATOMY AND PHYSIOLOGY OF THE OVARY AND OVIDUCT. 
 
 An Extra Ovary. Societe de biologie. Paris, 1875. Dr. De Sinety. 
 
 Anat. microscop. de I'oviducte de la Cestiide. Lataste. Arch, de phys. No. 3. 1876. 
 
 Der Nebenstock des Weibes. Kobelt. Heidelberg, 1847. 
 
 Eierstock und Ei. Waldeyeii. Leipsic, 1870. 
 
 Histoire generale et particuliere du developement des corps organises. Coste. Paris, 
 
 1847. 
 Homology of the Sexual Organs. Morrison Watson. Journal Anatomy and Phys- 
 iology. 1879. 
 Ou the Development of the Ova and Structure of the Ovary. FOULIS. Trans. Roy. 
 
 Soc. Edin. , 1875 ; and Journal Anat. and Physiol. Vol. XIII. 
 On the Formation of Ovules, and the Ovary of Mammalia and Oviparous Vertebrata. 
 
 O. Cadiat. Memoires de I'academie des sciences, Feb. 23, 1880. 
 Ovaire pendant la grossesse. De Sinety. Archives generales. I. 1877. 
 Ovaire sumumeraire. De Sinety. Ann. de gynecologie. Vol. VII. 
 Ovulation et menstruation. De Sinety. Ann. de gynecologie. Vol. VII. 
 Phenomena accompanying the Maturation and Impregnation of the Ovum. F. M. 
 
 Balfour. Quarterly Journal of Micrcscopical Science, April, 1875. 
 Researches on the Ovary of the Foetus and New-born Child. De Sinety. Paris, 1875. 
 Recherches sur I'ovaire du foetus. De Sinety. Archives de physiologic. No. 5. 1875. 
 Recherches sur les corps de Wolff. Follin. Paris, 1850. 
 Recherches sur les ovules et sur I'ovaire. Par M. 0. Cadiat. Academic des sciences, 
 
 Feb., 1880. 
 Researches upon the Supra-renal Bodies and the Ovary. G. Creighton. Joum. 
 
 Anat. and Phys. Vol. XIII. 
 Sachs : Text-book of Botany. London, 1875. 
 Structure and Development of the Vertebrate Ovary. By F. M. Balfour. Quarterly 
 
 Journal of Microscopic Science. No. LXII. 1878. 
 Traite pratique des maladies de I'uterus, des ovaires et des trompes. Par Prop. Cour- 
 
 ty. Paris, 1872. 
 1
 
 2 DISEASES OF THE OVARIES. 
 
 Ueber Accessorische Ovarien. Dr. Herman Beigl. Wiener medizin. Wochensch. 
 Heft 13. 1877. 
 
 Upon the Formation and Significance of the Corpus Luteum in the Ovary. Otto 
 Spiegelberg. Monatschrift fiir Geburtskunde. 1807. 
 
 Uterus and its Appendages. Arthur Farre. Encyc. Anat. and Physiology. Supple- 
 mentary vol. 
 
 Zur intrauterinen Entwickelung der Graaf schen Follikel. Dr. Haussman. Berlin, 1875. 
 
 Zur normalen und pathologischen Histologic des Graafschen Blaschens des Menschen. 
 Slawianski. Virchows Archives. Band LI. 
 
 Within the last ten years there has grown up a taste— per- 
 haps I had better say a fashion, lest it should not prove perma- 
 nent — for popular instruction in biology, and this tendency has 
 had results of the best kind. Among others, it has enabled us 
 to teach women, even girls, a great deal which deeply concerns 
 their welfare, in a way which cannot, or, at least, ought not to 
 offend any. It must ever be regarded as a misfortune that the 
 most important functions of life, those of reproduction, and the 
 most important relations of society, those of marriage, have 
 usually been shrouded in mystery and darkness, have been 
 wilfully misrepresented to the inquiring and innocent mind of 
 youth, and have been left entirely for their solution to the per- 
 sonal speculations or experiment of each adolescent. 
 
 Now, by simply telling the life-history of a flower, and by 
 the gentlest hint that what is true there is true all through life 
 up to its highest developments, we may convey all the instruc- 
 tion that is needed, and all that is demanded in, the interests of 
 humanity. Teach a child the functions of the anther, the stig- 
 ma, the pollen, the ovary, and the seed-capsule : let him or her 
 see the conjugation of the spirogyra, and the child will be armed 
 with a knowledge which will do much to prevent mischief both 
 moral and physical. 
 
 Between the simple mass of protoplasm enclosed in a struc- 
 tureless capsule of cellulose, which forms the ovum of the alga, 
 up to the complex ovum of the mammal, with its vascular folli- 
 cle, there is a marvellous difference in elaboration of detail, but 
 no difference in principle. The cellulose capsule is ovary and 
 uterus in one, and the conjugating buds are at once vagina and 
 oviduct ; and from this simplicity the complexity arises only 
 from specialization of structure, and not from the introduction 
 of anything new in principle. 
 
 In the algce, and in many other instances even in animal 
 life, as the aphides, we have two principles of reproduction, or 
 rather of continuation : the first is the production of the zoo- 
 spore (swarm-spore), which is effected without the conjunction 
 of two cells, and of which we have the solitary trace, in mam-
 
 AXATOMY AND PHYSIOLOGY OF THE OVARY. 3 
 
 mals, of the so-called dermoid tumor of the ovary ; the second 
 method is the formation of the zygospore (resting-spore) by the 
 conjunction of two elements, male (pollen-grain, antherozoid, 
 or spermatozoid) and female (ovule, oospore, germ-cell, germinal 
 vesicle), and with that process alone the human ovary has to do 
 in its complete function. It must not be forgotten, however, 
 that the zoospore and the female part of the zygospore are 
 essentially the same, that their fundamental functions are ex- 
 actly the same, and that the properties introduced by the addi- 
 tion of the sperm-cell seem rather to be an extension of those 
 already existing than the creation of new ones. How far this 
 analogy is extended to mammals, and especially to man, and 
 how far it has been curtailed, is one of the most interesting 
 questions of biology ; and yet it is one upon which we have as 
 3'et absolutely no information. 
 
 Much unnecessary confusion has been introduced into physio- 
 logical writing and teaching by the use of different names for 
 the same thing in different places. I must here repeat the pro- 
 test I have frequently made, in my lectures on biology, against 
 this practice, and my prediction that the whole of our nomencla- 
 ture will have to be revised and this confusion reduced to order. 
 For example, why should the male element be called a pollen- 
 grain in the foxglove, an antherozoid in an alga, and a sperma- 
 tozoid in a mollusk ? It would be much better to call it an anther- 
 ozoid in every instance, and still better would it be to drop our 
 old-fashioned names, as Graafian follicle, discus proligemis, in 
 human anatomy, and give to these structures names like oogo- 
 nium, which would indicate their common and real biological 
 significance. 
 
 It is, I fear, beyond my power to introduce such a reform, 
 yet in the following pages I shall do my best to make such terms 
 more familiar to the purely medical reader. 
 
 It is wholly impossible to discuss the pathology and treat- 
 ment of the diseases of a structure like the ovary without a full 
 understanding of its anatomy and physiology; and here we en- 
 ter upon a field vast and as yet unexhausted. During the last 
 twenty years perhaps no organ in the body has been so much 
 written about as the ovary; yet much remains to be told, and 
 still more to be discovered. To the naked eye nothing could 
 look more uninteresting and unimportant than a human ovary; 
 and yet upon it the whole affairs of the world depend. As far 
 as the individual owner of the gland is concerned — certainly 
 for her comfort, and, if we take with it its appendages, for her 
 life as well, it is the most important organ in her body. 
 
 The descriptions given of the rough anatomy of the organ
 
 DISEASES OF THE OVARIES. 
 
 coincide, of course, closely enough ; but between those of its mi- 
 nute structure, its development, and the processes carried on in 
 it, there is considerable diversity of opinion. 
 
 From 1870 to 1875 I was much engaged in these investiga- 
 tions, but since then I have been too much engaged in practice 
 to follow them out as fully as has been done by others, more 
 particularly by Mr. F. M. Balfour, the distinguished embryolo- 
 gist. With his conclusions and descriptions, my own work, so 
 far as it has gone, most closely agrees, and therefore, in this 
 part of my subject, I am greatly indebted to his papers for my 
 descriptions ; and while I do not desire to depreciate the efforts 
 of other workers, I am bound to say that Mr. Balfour gives by 
 far the most consistent and complete results. 
 
 The ovaries are, like most other organs in the body, bilater- 
 ally symmetrical ; that is, they are similarly situated, one on each 
 side ; yet here the usual rule of differences occurs, for I never 
 have seen two ovaries from the same person exactly alike in 
 situation, size, shape, or appearance. Infinite variety in all such 
 details are to be observed, and any description can only be one 
 which is applicable to a particular instance, or one of the average 
 appearances. 
 
 The size of the ovaries varies with the different periods of 
 life; and, to a less extent, so does their distance from the uterus. 
 Henning's table of measurements is given below, the chiefly 
 noteworthy fact given there being that the ovary is largest in 
 the first six weeks after parturition. This may have been due 
 to some pathological condition in those examined ; but in con- 
 nection with this it is curious to note the statements of horse- 
 breeders, that a mare is more readily impregnated soon after the 
 birth of a foal than at any other time. 
 
 Henning's Table of the Size an<} Position, of tlie Omries nt different Periods of Life and 
 in vafious Social Conditions, in Centinietres. 
 
 P 
 
 ^ 
 
 fl 
 
 a 
 
 i Right., 
 "( Left . . . 
 ( Right . . 
 ■( Left . . , 
 j Right., 
 ( Left.., 
 Distance from the \ Right . 
 uterus ^ Left . . , 
 
 No. of cicatrices -, t «i ' 
 
 / Left . . , 
 
 Length of the ovary . 
 Breadth " " 
 
 Thickness ' 
 
 1.8 to: 
 
 0.2 to 1.4 
 
 0.2 to 0.6 
 
 1.0 to 4.0 
 1.2to8.7 
 
 
 
 
 
 3.8 
 3.7 
 1.9 
 1.5 
 
 3.4 
 3.8 
 1.8 
 1.7 
 
 1.0 
 
 0.9 
 
 1.0 
 
 0.9 
 
 3.4 
 
 4.4 
 
 3.3 
 
 4.5 
 
 6 
 
 14 I 
 
 9 
 
 13 ! 
 
 3.0 
 
 2.5 
 
 4.4 
 
 2.8 
 
 2.4 
 
 5.5 
 
 1.7 
 
 1.2 
 
 1.3 
 
 1.5 
 
 1.2 
 
 1.4 
 
 1.0 
 
 0.8 
 
 0.8 1 
 
 0.9 
 
 1.1 
 
 0.9 
 
 4.7 
 
 5.5 
 
 8.0 
 
 4.7 
 
 5.0 
 
 7.0 
 
 21 
 
 22 
 
 8 
 
 21 
 
 21 
 
 8 
 
 3.5 
 3.2 
 1.6 
 
 1.7 
 0.8 
 0.8 
 3.8 
 4.2 
 
 3.5 
 3.1 
 
 -1.4 
 1.4 
 0.9 
 1.0 
 4.0 
 4.2 
 
 24 L-17 
 26 I 18 
 
 3.1 
 2.5 
 1.5 
 1.4 
 0.8 
 0.8 
 4.0 
 3 7 
 15 
 24 
 
 2.9 
 2.7 
 1.1 
 1.0 
 0.8 
 0.9 
 4.0 
 4.5 
 14 
 11
 
 ANATOMY AXD PHYSIOLOGY OF THE OVARY. 5 
 
 The color of the ovaries when perfectly healthy, and in the 
 living subject, is of a pinkish, pearly hue, with here and there a 
 hazy blueness showing through the tunic when a follicle is 
 either getting ready for the discharge of its nucleus or is disap- 
 pearing after having fulfilled its function. When a follicle is 
 either about to burst or has just burst, the site is of a purple- 
 brown color. The glands are oval in shape, and flattened from 
 before backward, the anterior surface being shorter and less 
 convex than the posterior, which is more rounded. The outer 
 extremity is also rounded and bulb-like, whilst the inner is some- 
 what pointed and thinned off into the broad ligament. By these 
 appearances the ovary of one side may be recognized from the 
 other, if the glands are healthy. The average weight of the 
 ovary is about ninety grains (Farre). 
 
 The glands are usually situated on a level with the inlet of 
 the true pelvis, behind the Fallopian tubes and round ligaments. 
 Looking down upon the broad ligament from above, whilst it is 
 on the stretch, it may be seen to be formed of three folds, of 
 
 Fig. 1.— Front view of left broad liarament (after Richard): a, pavilion and fimbrife: 6, body of the 
 tube: c. opening of infundibnlum ; d, tnbo-ovarian ligament (one of the fimbriae) ; e, uterine end of tube ; 
 /', nieso-salpinx ; g, ovary ; h, utero-ovarian ligament ; i, fundus uteri ; I, round ligament ; A, d, b, and I 
 are the three points of folding of the broad ligament. 
 
 which the ovaries occupy the posterior, the Fallopian tubes the 
 middle, and the round ligament of the uterus the anterior, all 
 these structures being enveloped by folds of the peritoneum in 
 the same way as is the uniform distribution of this most inter- 
 esting serous membrane.
 
 6 
 
 DISEASES OF THE OVARIES. 
 
 Fig, ~. — Diagram- 
 matic section of broad 
 ligament : 0, ovary : B, 
 Fallopian tube, showing 
 meso-salpinx ; D, meso- 
 varium. 
 
 Recent German writers, especially Waldeyer and Leopold^ 
 have asserted that on the posterior surface of the ovary the 
 peritoneal layer does not exist. If so, it has become incorporated 
 with the underlying coat, the tunica albuginea 
 of after-life, for it must obtain a peritoneal cov- 
 ering during its developmental transition. If we 
 consider these facts for a moment, we must con- 
 clude that the ovary must be enveloped by both 
 an anterior and posterior layer, just as a piece of 
 small intestine is, for the mesovarium always 
 has two distinct layers. 
 
 Although in the after-life of the gland this 
 posterior layer cannot be removed by the scalpel, 
 it is represented by a layer of squamous epitheli- 
 um, which covers the whole surface of the gland. 
 I have undertaken a special research on this 
 subject, and find that the posterior surface, 
 when treated by silver and other staining meth- 
 ods, displays the same stomata and stigmata as 
 does the anterior surface, or indeed any other part of the serous 
 surface, provided the delicate arrangements are not disturbed 
 by clumsy handling or by chemical reagents. In this way I have 
 satisfied myself that the statement that the posterior surface of 
 the ovary is destitute of peritoneum is incorrect. 
 
 The broad ligament, derived from the foldings already allu- 
 ded to, is composed of a process of peritoneum by which the 
 membrane, leaving the anterior abdominal wall and the base of 
 the bladder, bends upward over the fundus of the uterus and 
 the upper margin of the Fallopian tube, as far outward as its 
 opening. It then dips down behind the uterus as far as the cer- 
 vix, and passes backward and upward over the rectum. Just to 
 the outside of the uterus it bends upward, over, and then down be- 
 hind the round ligament of the uterus. Then over the Fallopian 
 tube it bends down for a distance varying from half an inch to 
 two inches, and makes a very distinct meso-salpinx, at the end of 
 which the peritoneal cavity is opened into by the infundibulum. 
 From the lower margin of this, the folds are continued in an out- 
 ward direction to the lateral parietes. From the posterior sur- 
 face of the meso-salpinx the posterior fold bends upward over 
 the anterior surface of the ovary in very many instances, though 
 in others it passes straight over the gland from its upper margin 
 on to its posterior surface — in such cases no mesovarium being 
 found. 
 
 In a few exceptions I have seen a crescentic double fold of 
 the posterior layer of the broad ligament pass down behind the
 
 AISTATOMY AND PHYSIOLOGY OF THE OVAllY. 7 
 
 ovary, covering it like the hood of a "Nepenthes" gland. In all 
 such cases the women have been sterile, probably because this 
 hood has prevented the application to the ovary of the opening 
 of the oviduct. I have seen this arrangement give great trouble 
 in the removal of small ovaries. 
 
 From the lower margin of the ovary the peritoneum passes 
 downward to the flexure of the recto-uterine cul-de-sac. Be- 
 tween these two folds, besides the tubes and the ovaries, are to 
 be found the parovarium on the outer side, the utero-ovarian 
 ligament on the inner side, and some irregular and faintly 
 marked bundles of muscular fibre, besides a quantity of loose 
 connective cellular tissue. 
 
 Behind the right ovary lies the small intestine, and behind 
 the left is the rectum — a fact of great importance in some of the 
 pathological features of the gland. The ovaries, the parovarium 
 and the Fallopian tubes, and the vessels which supply them, lie 
 outside the peritoneum really, and this also is a most important 
 fact in their various diseases. The blood-vessels are the utero- 
 ovarian and ovarian arteries and veins — the former derived from 
 the internal iliac vessels, the latter from the aorta and vena 
 cava. These latter vessels possess so much practical interest 
 that a few words of special description must be given concerning 
 them. The arteries, which are the homologues of the spermatic 
 arteries in the male, arise from the aorta just below the renal 
 branches, and pass obliquely downward over the psoas muscle. 
 When they reach the brim of the pelvis they turn inward and 
 forward (centrally toward the middle point), and run up to the 
 ovaries between the folds of the broad ligament. They give off 
 branches to the Fallopian tube and to the side of the uterus, 
 where they anastomose freely with the branches of the uterine 
 arteries derived from the internal iliac. 
 
 The veins have an analogous distribution. They arise from 
 a venous plexus lying below the ovary and between it and the 
 uterus — the so-called bulb of the ovary (Rouget). which has a 
 free communication with the venous plexus at the side of the 
 uterus. From this the ovarian veins have a direction corre- 
 sponding with that of their arteries, with this important distinc- 
 tion, that the vein on the right side enters the inferior vena cava 
 at an acute angle, and on the left side the vein joins the renal 
 vein at a right angle. 
 
 It has long been known that, in the male, varicocele is much 
 more frequent on the left side than on the right, and the expla- 
 nation usually given of it was the pressure which is, or may be, 
 exercised on the left spermatic vein by a loaded rectum. A 
 much more exact explanation has resulted from a careful study
 
 8 
 
 DISEASES OF THE OVAKIES. 
 
 of these veins by Dr. J. H. Brinton, of Philadelphia. His deduc- 
 tions from a carefully made series of inquiries result in the fol- 
 lowing : 
 
 1. That the causes hitherto assigned are insufficient to account 
 for the rare occurrence of varicocele on the right side. 
 
 2. That the cause of this non-occurrence is to be referred to 
 the existence of a very perfect valve, hitherto unnoticed, at the 
 termination of the right spermatic vein in the vena cava. 
 
 3. That no such valve exists upon the left side, at the junc- 
 tion of the spermatic with the renal vein. 
 
 Fia. 3. — Dissection of the vena cava, emnlgent and ovarian veins, showing the right ovarian valvo: 
 a, right ovarian vein; /, left ovarian vein, without valve : v, valve ; «, sinus in front of valve. 
 
 4. That a similar valve exists in the analogous vein of the 
 female — the right ovarian vein — but that there is none on the 
 left side. (See Fig. 3.) 
 
 In this I think there is only one error to be noted : that is, 
 that Dr. Brinton believes these valves have not before been no-
 
 ANATOMY AKD PHYSIOLOGY OF THE OVARY. 9 
 
 ticed. This is not correct, for in the third edition of Gray's 
 '• Anatomy '' (1864), now before me, it is distinctly stated that the 
 spermatic veins have valves. Dr. Brinton's merit consists rather 
 in showing that the left vein has not a valve, whilst tlie right 
 vein is provided with one. 
 
 The physiological fact we have further to bear in mind con- 
 cerning these veins is that during pregnancy they increase enor- 
 mously in size. These facts explain those distressing cases of 
 chronic ovaritis and ovarian hypera^mia which often start after 
 a first confinement, and which are most frequently characterized 
 by the greatest suffering being in the left ovary, which is always 
 enlarged, and often dislocated down behind the uterus. These 
 cases are often so intractable as to demand the removal of the 
 ovaries as the only method of permanently curing the patients. 
 
 The nerves of the ovaries are derived from the spermatic 
 plexus, which in its turn is derived from branches from the re- 
 nal and aortic plexus. The spermatic nerves accompany the 
 arteries to the ovaries. The Fallopian tube has a special branch 
 from one of the uterine nerves — in this, as in other details, show- 
 ing its method of development. 
 
 Dr. Elischer, from investigations made in the laboratory for 
 embryological research of Prof. Michalkovics, in the University 
 of Buda-Pesth, has satisfied himself that the nerves of the ovary 
 in mammals enter into the substance of the organ in the form 
 of meduUated fibres accompanying the looped and tortuous ves- 
 sels that pass to the hiluni, and run also in the proper ligament of 
 the ovary. Some of the fasciculi branch dichotomously till they 
 reach the follicular layer of the periphery, where they lose their 
 medullary sheath, and form loops around the follicles. Others 
 form a coarse plexus around the vessels. The more mature the 
 follicle — that is to say, the thicker the membrana granulosa — by 
 so much the more distinctly can a still somewhat coarse plexus 
 be seen of tolerably thick nerve-fibres in the substance of the 
 follicular investment ; and from this plexus another plexus, 
 composed of more delicate fibres, forming a more elongated net- 
 work, with numerous knots and varicosities, can be seen to arise, 
 which is applied to the outer layer of the membrana granulosa. 
 Some of the branches, he thinks, penetrate the cells of the mem- 
 brana granulosa, and run up to the nucleus. He recommends the 
 ovary of the sheep as the object best adapted for investigation. 
 
 Besides the normal pair of ovaries, accessory glands — or per- 
 haps, to speak more correctly of most of the cases, separated 
 cotyledons — are met with. I have not seen an example of these, 
 and my description is taken chiefly from the observations of 
 Herman, De Sinety, and Beigl.
 
 10 DISEASES OF THE OVAEIES. 
 
 Herman was, so far as I know, the first author to notice 
 these interesting structures, and he describes the appearances in 
 the body of a newly born child, where, on the border of one of 
 the ovaries, there was a small, pedunculated body, which proved 
 to be composed of normal ovarian tissue, with its follicles and 
 epithelium, and having in the centre an ovum with its macula 
 germinativa. Dr. De Sinety rather si)oils his interesting obser- 
 vation by suggesting that his case is especially noteworthy from 
 the probability that, if the patient had lived, she would have 
 been the subject of extra-uterine pregnancy. This is, of course, 
 nonsense ; but if she had had both ovaries removed for disease, 
 she might have gone on menstruating if this adventitious struc- 
 ture had been left ; and it is possible that some of the cases of 
 continued menstruation, after the removal of both ovaries, may 
 have their peculiarity from some such cause as this. Similarly 
 she might have been the subject of a third ovarian tumor. 
 
 Dr. Beigl has found similar structures eight times out of three 
 hundred and fifty examinations. They were always situated at 
 the hilum of the ovary, at the line of demarcation of the peri- 
 toneum (Waldeyer's line), and they varied in size from that of a 
 hemp-seed to that of a small cherry (about 8 mm.). They gen- 
 erally were set upon slender pedicles, and as many as three were 
 found associated with the same ovary. The subjects in which 
 they were found were of all ages, and the substance of the 
 structures was true ovarian tissue. 
 
 Waldeyer has described one instance in which as many as 
 six of these additional or accessory ovaries, as he calls them, 
 were found ; but he regards them, in some instances, as out- 
 growths from the ovary in the later stages of its development. 
 He names them ''Nebeneierstocke," which is evidently open to 
 the objection that German writers have already applied that 
 name to the parovarium. In doing so they are, however, mis- 
 taken, and I think Waldeyer right upon this point. 
 
 These accessory ovaries show, by the active growth of their 
 follicles, that they have a distinct physiological importance. 
 
 Before entering upon the difficult and complex subjects of the 
 development and minute structure of the ovary, a few words 
 must be said upon the oviduct and that representative structure, 
 the parovarium, as both of these have great importance in the 
 diseases which truly belong to, or which may simulate the true 
 diseases of the ovary. 
 
 In some of the lower orders of fishes (ganoid) the ovaries shed 
 their ova, as soon as they are ripened, into the peritoneal cavity, 
 whence they escape by the abdominal pores, to be fecundated
 
 ANATOMY A^B PHYSIOLOGY OF THE OVARY. 11 
 
 outside by the shed sperm of the male, as in all fishes. In such 
 cases there is free communication between the peritoneal cavity 
 and the outside water. In higher orders the ovaries are tubular 
 glands, the tubes being continued, as oviducts, to the outside, 
 opening above and behind the anus. In all other vertebrata 
 there is a break between the oviduct and the ovary ; and the 
 higher we go in the animal scale, the more complex does this 
 oviduct become, till we get to the marsupialia and mammalia, 
 when a part of it is specialized for the retention of the embryo 
 till it is less or more ready to maintain an independent existence. 
 
 At an early period of embryonic life in the mammal the pri- 
 mordial kidneys (Wolffian bodies) are each symmetrically pro- 
 vided with a duct — the Wolffian duct — which passes backward 
 along the outer side of its corresponding gland, and opens pos- 
 teriorly into the sac of the allantois. 
 
 Somewhat later another duct appears on the anterior surface 
 of each Wolffian body, but remains throughout its whole extent 
 distinct from this gland, and never functionally connected with 
 it. Traced backward from the gland it soon comes in contact 
 with the Wolffian duct, and together they form the genital cord. 
 The Miillerian duct opens at its anterior extremity into the 
 pleuro-peritoneal cavity, and posteriorly into the sac of the al- 
 lantois. In the male the Wolffian ducts persist, and ultimately 
 form the vasa deferentia, whilst the Miillerian ducts atrophy, 
 with the exception of a small portion, which persists as the vesi- 
 cula prostatica, or male uterus. 
 
 In all animals but the didelphous and monodelphous mam- 
 malia, the Miillerian ducts undergo no further modification of 
 any great morphological importance, save in birds, where the 
 right duct is atrophied at an early period and the left only is 
 developed. But in the monodelphous inammalia the two ducts 
 become united at a short distance from their posterior openings, 
 and then, by the disappearance of the coalesced wall, form a 
 vagina with two uterine openings; or, by a further coalescence, 
 form a single vagina and a single uterus, into which two Fallo- 
 pian tubes open, these tubes being the survivals, in the higher 
 mammals, of the two Miillerian ducts, retaining their openings 
 into what was the pleuro-peritoneal cavity before its division by 
 the diaphragm. In some didelphous mammalia the two tubes 
 remain separate throughout their length, giving two vaginte, 
 two uteri, and two Fallopian tubes, and instances of all the vary- 
 ing conditions found in antecedent animals are found occasion- 
 ally in women as reversions. 
 
 In female mammals the Wolffian ducts disappear almost en- 
 tirely in most species, being permanently and constantly repre-
 
 12 
 
 DISEASES OF THE OVAKIES. 
 
 sented only by the apparently functionless organ of Rosenmiiller 
 (Figs. 4 and 5). When further survivals of them persist they 
 are known as the canals of Gaertner, which in a few niamnials, 
 
 Fig. 4 (after Kobelt). — View of oviduct and pai-ovarium from behind : a. a. inverted pyramid formed 
 by convoluted tubules of parovarium ; 6, outer tubules, flask-shaped, and oftt-n dilate<l into cysts ; e, atro- 
 phied Wolffimi duct, or canal of Gaertner (lower down) ; /, terminal bulb of Wolffian duct, known as organ 
 of Hosenmuller; A. P'allopian tube, or altered Miillerian ducts" i, terminal bulb of same, known as the 
 hydatid of ilorgagni in the male. 
 
 as the cow and the pig, retain a large size, but serve no purpose, 
 so far as is known. They commence above, lying in close rela- 
 tion to the organ of Rosenmuller (e, Fig. 4), and run down either 
 
 in the substance of the ute- 
 \ " '\ rus, or close to it, between the 
 ; /' layers of the broad ligament. 
 \ • They open into the uro-geni- 
 // tal sinus on either side of the 
 / / meatus urinarius. In excep- 
 
 // tional cases they are found 
 
 in women, and even during 
 life their openings in the posi- 
 tion indicated may be clearly 
 seen. 
 
 When, in the human em- 
 bryo, the coalescence of the 
 two tubes has so far ad- 
 vanced as to form the utero- 
 vaginal canal, the remaining 
 part of the tube is bent 
 sharply downward and out- 
 ward, and thereafter occu- 
 pies its normal (nearly) hori- 
 zontal position. It leaves the uterus at the cornu (ostium inter- 
 num), at this part of its course through the uterine tissue being 
 
 Fig. 5 (after Kobelt). — Wolffian body and ovaiy of 
 embr\ o of the sixth week : a. a. tubules of Wolffian 
 body ; e, excretory duct ; /, terminal bulb (organ of Ro- 
 spninuUer) ; /«, Miillerian duct ; i, terminal bulb ((', Fig. 
 4) ; a", uro-genital sinus, into which both ducts open. 
 The dotted outline shows bent position of Miillerian 
 ■duct when it has become the Fallopian tube.
 
 Al^ATOMY AND PHYSIOLOGY OF THE OVARY. IB 
 
 of very narrow calibre. From this point it extends outward for 
 a distance varying in the adult from three to five inches, its 
 diameter increasing slightly as it leaves the uterus, and con- 
 tracting again at the ostium abdominale, where it opens out into 
 the infundibulum. It consists of three coats, one derived from 
 the folding over it of the peritoneum, as already described. The 
 greater part of its wall is therefore in direct contact with the out- 
 side surface of the peritoneum. The lesser portion of the wall 
 is in contact with the cellular tissue, which occupies the space 
 between the two folds of the broad ligament, at the lower aspect 
 of the tube (meso-salpinx) (Fig. 2). The middle coat is muscu- 
 lar, and consists of a faint layer of longitudinal fibres externally, 
 and a much thicker layer of circular fibres internally. The lon- 
 gitudinal fibres, according to my own observations, disappear 
 entirely about the menopause, or soon after. The internal or 
 mucous surface is thrown into a series of delicate longitudinal 
 folds by the action of the circular fibres, an arrangement exactly 
 similar to that which obtains in the oesophagus and urethra. 
 The mucous surface of the tube is lined with ciliated epithelium, 
 the movements of which are directed toward the uterus, and the 
 function of which is certainly to prevent the passage of sperma- 
 tozoa up the tube. If this were not so, tubal pregnancy would 
 be much more common than it is. The movement of the cilia 
 also undoubtedly aids the passage of the ovum down the tube, 
 and prevents its adhesion to the wall should the ovum happen 
 to become occupied by spermatozoa. At the ostium abdominale 
 the tube expands trumpet-like, the expansion being formed by a 
 series of fimbrise, or lacinia?, of two sizes, major and minor. 
 This infundibulum (known also as the worsus diaholi) (a, Fig. 1) 
 is large enough to embrace about one-third of the ovary, and 
 seems to have a curious tendency to enlarge as the ovary en- 
 larges in diseased conditions. The major fimbriae have the mi- 
 nor fimbriae arranged between them somewhat irregularly, and 
 when a Graafian follicle is nearly ready to burst, the infundibu- 
 lum is said to be applied over the part of the ovary where the 
 ripe follicle is and becomes attached to the surface by a slight 
 cellular adhesion. If so, there must be some peculiar and wholly 
 unknown selective influence which governs this adhesion, but it 
 clearly is a mechanism not of universal or constant accuracy; 
 for I have frequently, during abdominal sections, seen follicles 
 just on the very point of bursting, over which the infundibulum 
 was not fixed. In such a case the ovum must fall free into the 
 peritoneal cavity, and there probably dies in the great majority 
 of instances. There is reason to suspect, however, that, in ex- 
 ceptional instances, it there undergoes cystic expansion.
 
 14 DISEASES OF THE OVARIES. 
 
 The infundibulum is covered by transitional columnar epithe- 
 lium, and at the margin of the fimbriae it meets the squamous 
 epithelium of the peritoneum, forming the only instance of the 
 union of a mucous and a serous surface — in fact, the unique in- 
 stance of an opening into a serous cavity. 
 
 Under ordinary circumstances, when the tube is healthy, its 
 cavity is occupied by a small quantity of viscid mucus, and dur- 
 ing menstruation this is replaced by blood of the usual dark, 
 fluid character. Inflammation may occlude both ostia, and con- 
 vert the tube into a cyst, occupied by serum (hydro-salpinx) or 
 by blood (hsemato-salpinx), or by pus (pyo-salpinx), of which 
 conditions I have seen quite a number of cases. 
 
 Normally the tube lies loose in front of the ovary, and rather 
 below its level, coiling around it till the infundibulum turns 
 toward the middle line and backward toward the posterior sur- 
 face of the gland. This bend of the tube may be actually below 
 the ovary, but, as far as the structures of the broad ligament 
 are concerned, it is, of course, above it. From the lower margin 
 of the mouth of the tube extends the tubo-ovarian ligament, 
 formed by one of the major flmbrias {d, Fig. 1), and which seems 
 to serve as a guide for the tube in its movement toward the 
 ovary. From the posterior lip of the funnel depends the ter- 
 minal bulb of Miiller's duct, though it is by no means always 
 present. 
 
 The parovarium is the remains of the tubular structure of 
 the primordial kidney, or the Wolffian body. It lies between 
 the two layers of the broad ligament, between the upper and 
 outer margin of the ovary and the Fallopian tube. It has the 
 shape of an inverted pyramid (Fig. 4), the apex being applied to, 
 but not attached to, the ovary. The tubules vary much in num- 
 ber — from three or four to thirtj^ They have always cgecal ex- 
 tremities, and those on the outer side are always best marked, 
 the outermost one forming the terminal bulb or organ of Rosen- 
 miiller. If a good example of the structure be carefully dis- 
 sected, it will easily be determined that the tubes are lying loose 
 in the cellular tissue of the broad ligament, and are not attached 
 to either of its layers or to the ovary. This explains a char- 
 acteristic feature of those Wolffian cysts which require opera- 
 tion. From the inner and upper angle of the parovarium runs 
 the atrophied Wolffian duct — that is, when it is visible, which is 
 not often the case. This duct is so thoroughly atrophied that I 
 do not think any of the tubules have intercommunication, as 
 they would have if it were not. 
 
 Of the three layers of the blastoderm which form, by various
 
 ANATOMY AND PHYSIOLOGY OF THE OVAIIY. 
 
 15 
 
 and most curious plications and developmental changes, the 
 many organs of the body, only two — the mesoblast and hypo- 
 blast — take part in the formation of the organs we are consid- 
 ering. 
 
 The first change consists in an arrangement of cells which, 
 radiating from a centre which forms a lumen, is found to travel 
 down through the mesoblast from its dorsal surface, immedi- 
 ately under the epiblast, just outside the protovertebra?, between 
 them and the pleuro-peritoneal cavity. This cavity is then lined 
 by the epithelium, which ever afterward is its marked charac- 
 teristic, and which then is 
 known as the germinal 
 epithelium. In the chick, 
 as early as the second day, 
 this cellular track can be 
 traced downward as a 
 distinct ridge (Balfour), 
 and it forms the primitive 
 WoljBian duct. In other 
 animals the changes are 
 probably much the same, 
 but for obvious reasons 
 they have not been traced 
 in sequence, and their 
 dates are unknown. The 
 next change is the appear- 
 ance of a cell-mass out- 
 ward into the pleuro-peri- 
 toneal cavity, in which the 
 Wolffian body is formed, 
 consisting, like the per- 
 manent kidneys, of con- 
 voluted tubules, commen- 
 cing in Malpighian bodies 
 with vascular glomeruli, and opening into the duct. Upon this 
 cellular mass lies the germinal epithelium of the pleuro-perito- 
 neal cavity, from which the ovary is formed on the inner side of 
 the Wolffian body — that is, the side looking toward the splanchno- 
 pleure. The germinative epithelium retains its columnar charac- 
 ter, and becomes thickened to several cells deep, the mesoblast 
 below it becoming also thickened, so that a distinct eminence 
 is formed as a fusiform white patch or streak, extending, 
 in its early stages, along the whole length of the Wolffian 
 body, but subsequently becoming restricted to its superior por- 
 tion. In the cells of the germinal layer are found the primitive 
 
 Fig. 6 (after Balfour). — vi, mesentery ; X, soniaiopleure ; a', 
 portion of the gerniiiial ejiithelium from which the involution 
 to form the duct of Miiller (z) takes place ; a, thickened portion 
 of the germinal epithelium in which the primitive ova (C) and 
 (o) are lying ; E, modified mesoblast, which will form the 
 stroma of the ovary ; WIC, Wolffian body ; j/. Wolffian duct.
 
 16 
 
 DISEASES OF THE OVARIES. 
 
 ova, developed by differentiation from the epithelial cells. 
 This change is effected in the chick about the ninetieth hour of 
 incubation, at which time it is quite possible to determine the 
 difference of sex. In the human embryo the difference is not 
 discernible till between the fifth and seventh weeks, authorities 
 differing materially as to the exact date. 
 
 The structure of the early ovary consists of a superficial layer 
 of the germinal epithelium {g, e. Fig. 7), and of a tissue internal 
 to this which forms the great mass of the gland. 
 
 The germinal epithelium is a layer about 0.03 to 0.04 mm. 
 in thickness, having two or three layers of cells with granular 
 nuclei. The outermost layer is more columnar than the others, 
 and its cells have nuclei rather elongated than round. The cells 
 of this layer, though varying in size, have a larger provision of 
 protoplasm. 
 
 The tissue of the body of the gland consists mainly of col- 
 umns of epithelial-like cells, which stain more deeply with osmic 
 acid than those of the germinal layer, having round nuclei and 
 a more limited amount of protoplasm. Between its columns 
 
 runs up vascular stroma, 
 formed of spindle-shaped 
 and nucleated cells {t. Fig. 
 ?). This tissue continues 
 visible through the whole 
 course of the development 
 of the ovary, till compara- 
 tively late in life, and dur- 
 ing all the earlier stages it 
 might be easily supposed 
 to be playing some impor- 
 tant part in the develop- 
 ment of the ova, or to be a 
 part of the germinal epithe- 
 lium, from which it has 
 only occasionally any well- 
 marked line of demarca- 
 tion. In this tissue and at 
 the base of the ovary are 
 seen a number of canals 
 which have given rise to 
 the view advanced by 
 Pfliiger, that the ovary was developed as a tubular gland. This 
 view has, however, been almost universally abandoned, and, in 
 my own researches, I have seen no evidence which entitles it to 
 serious consideration. These tubules are clearly derived from 
 
 Fig. 7 (after BalfoiirV — o- «. germinal epithelium ; <, 
 trabecular ; A, hilum, with canal.
 
 ANATOMY AND PHYSIOLOGY OF THE OVAKY. 
 
 17 
 
 Fig. 8 (after Balfour). — p, o, primi- 
 tive ova ; t a, tunica albuginea ; c, e, 
 central epithelium. 
 
 the Malpigliian bodies of the Wolffian structures, and are mere 
 survivals. 
 
 The germinal epithelium grows rapidly in thickness by the 
 division of its cells, and the vascular 
 stroma greatly increases in quantity, so 
 that the epithelial tissue is honeycombed 
 by the vascular trabeculae, which are so 
 arranged as to divide imperfectly the 
 epithelium into two layers, separated by 
 a space occupied by connective tissue 
 and blood-vessels. The outer part is 
 relatively thin, and is formed of a super- 
 ficial row of columnar cells, and one 
 or two rows of more rounded cells, 
 among which can be recognized the primitive ova (p, o. Fig. 8) 
 by their size, their granular nucleus, with the characteristic 
 reticulation, and their abundant pro- 
 toplasm. The inner layer is much 
 thicker, and formed of large masses 
 of rounded cells, and the two layers 
 are connected by numerous trabe- 
 culse, the stroma between which 
 eventually gives rise to the connec- 
 tive-tissue capsule, or tunica albugi- 
 nea of the adult ovary. 
 
 Subsequently in the course of de- 
 velopment the germinal epithelium 
 becomes still more thickened to .38 
 mm., and becomes marked into three 
 distinct layers (Fig. 9, g, e). These 
 consist of an outer epithelial layer, 
 having an average thickness of .03 
 mm. ; a middle layer of small nests, 
 about . 1 mm. in thickness ; and an 
 inner layer of larger nests, which 
 has an average thickness of .23 mm. 
 In these three layers the epithelium 
 has undergone important modifica- 
 tions. The greater part of the gran- 
 ular contents of the nuclei of the 
 cells has become clear, the other 
 part remaining as a mass taking the 
 color of staining materials very 
 darkly, and somewhat later taking 
 a stellate figure, these two forms being spoken of as the granular 
 2 
 
 Fig. 9 (after Balfour). — g, e. germina! 
 epithelium in three layers ; A, hilum, with 
 canals, c c.
 
 18 DISEASES OF THE OVAEIES. 
 
 and stellate stages of the nucleus. Still later the nuclear mass 
 forms a beautiful reticulation, as seen in the spores of the algse. 
 
 As already said, some of the cells enlarge, and are recognized 
 as the primitive ova, and these are now increased in number. 
 Others of the cells again diminish in size, becoming of an oval 
 form, the nucleus retaining its primitive character, and not 
 going through the changes above described. The cells subse- 
 quently form the epithelium of the Graafian follicle. They may 
 be seen arranging themselves around the primitive ova just 
 formed. At the hilum of the ovary the tubules (c, c, Fig. 9) 
 have by this time almost disappeared. 
 
 As the ovary grows, the outermost layer of the epithelial 
 elements becomes more and more separated by the fusiform-cell 
 stroma, and the nests of the middle layer become smaller, and 
 finally the arrangement and formation of the Graafian follicles 
 become completed, and in the typical epithelial nest are to be 
 seen fully-formed follicles with the permanent ova, completely 
 
 Fig. 10 (after BalfourJ.— Nest from Fig. 11 (after Balfour).— Typical 
 
 middle layer, showing formation of epithelial nest, 
 
 follicular epithelium : o. primitive 
 ovum : /e, cells forming follicular 
 epithelium ; do, cells which disap- 
 pear. 
 
 enclosed in a cavity occupied by fluid and lined by epithelium ; 
 smaller ova (d. o. Fig. 10) not so enclosed ; smaller cells {h, c), 
 with modified nuclei of doubtful destination ; and small cells 
 (/, e) obviously about to form follicular epithelium. The inspec- 
 tion of a single such nest, says Mr. Balfour— and in this I fully 
 concur — is sufficient to show that the follicular epithelium takes 
 its origin from the germinal epithelium, and not from the stroma 
 or tubulif erous tissue. 
 
 Concerning the small cells with modified nuclei, Mr. Balfour 
 suggests three possibilities, and thinks they may have all three 
 destinations : that they become cells of the follicular epithelium, 
 are developed into ova, or are absorbed as a kind of food by the 
 developing ova.
 
 ANATOMY AND PHYSIOLOGY OF THE OVARY. 
 
 19 
 
 Jo 
 
 The isolated follicles are now formed by ingrowths of the 
 ■connective-tissue stroina cutting off fully -formed follicles from a 
 nest. They occur only at the very innermost border of the ger- 
 minal epithelium. This is in accordance with what has so often 
 been noticed about the mammalian ovary, viz., that the more ad- 
 vanced ova are to be met with in passing from without inward. 
 In the further growth of the ovary the pseudo-epithelium is 
 formed of a single layer of columnar 
 cells with comparatively scanty proto- 
 plasm. In it there are present a con- 
 siderable number of developing ova. A 
 layer of connective tissue, the albuginea, 
 exists below the pseudo - epithelium, 
 which contains a few small nests with 
 very young permanent ova. In the layer 
 of medium-sized nests internal to the 
 albuginea the ova hav^e all assumed the 
 permanent form, and are provided with 
 beautiful reticulate nuclei with a nucle- 
 olus and smaller granular bodies. The 
 majority are not provided with follicular 
 investment, but among them are numerous small cells, clearly 
 defined from the germinal epithelium, which are destined to 
 form the follicle (Fig. 13). 
 In the innermost layer of 
 the germinal epithelium 
 the outlines of the origi- 
 nal large nests are still 
 visible, but many of the 
 follicles have been cut off 
 by ingrowths of stroma. 
 
 Fig. 12. — Further development of 
 processes seen in Fig. 10. 
 
 The general conclu- 
 sions from Mr. Balfour's 
 researches are that the 
 whole Q^^ - containing 
 part of the ovary is really 
 the thickened germinal 
 epithelium, and it differs 
 from the original thick- 
 ened patch or layer of 
 germinal epithelium 
 mainly in the fact that 
 
 it is broken up into a kind of meshwork by growths of vascular 
 stroma. 
 
 Fig. 13. — Section of ovary of human embryo at third month 
 (after KoUiker), slightly magnified : a, mesovarium • a', vas- 
 cular stroma of hilus ; 6, gland-substance. X 50.
 
 20 
 
 DISEASES OF THE OVARIES. 
 
 It will be seen, therefore, that the formation of true Graafian 
 follicles goes on very early in the life-history of the ovary, long- 
 before the birth of the child, a fact which was pointed out by 
 Valisneri in 1733, but which received but little attention until 
 the writings of Carus (1837) and Ritchie (1842) attracted atten- 
 tion to this most interesting subject. Since then it has been most 
 exhaustively discussed by many observers, and finally, and, as 
 I think, conclusively unravelled by F. M. Balfour. The great 
 practical interest which it has for surgeons is that the dropsical 
 distentions of these follicles produce ovarian tumors occasionally 
 in very young children ; and Mr. Cullingworth, of Manchester, 
 has placed on record a most interesting observation where an 
 undoubted ovarian tumor existed in a newly born child, and 
 Virchow alludes to similar instances. By Mr. Cullingworth's 
 courtesy I have been able to examine his specimen, and I have 
 satisfied myself of the perfect accuracy of his description. 
 
 A most interesting observation is made by Dr. De Sinety, who 
 has been struck with the frequency of apparently cystic ovaries 
 in children at the time of birth, and especially a few days after, 
 and who has found, in the great majority of the ovaries of chil- 
 dren near the full term, or who die a few days after mature birth, 
 that Graafian follicles are visible to the naked eye, if sections of 
 the ovaries are made. He also says that these large follicles, 
 having arrived at a certain stage of development, begin to dis- 
 appear, and that the pro- 
 cesses of their retrogres- 
 sion and the different 
 phases of the cicatrices 
 which they leave behind 
 them can be followed. 
 He draws attention to 
 the fact, familiar to every 
 one, that it is no unusual 
 thing to see slight swell- 
 ing of the breasts of new- 
 ly born children, not only 
 female, but male, and the 
 secretion of a milky fluid. 
 This generally ceases in 
 a few days, and the gland 
 remains quiescent till the 
 puberty of girls, and 
 throughout life in boys. He thinks the ovarian activity is asso- 
 ciated with the premature mammary effort, and he quotes Mer- 
 kel ("Ueber die Entwickelung im inneren der Samenkanalchen," 
 
 Fig. 14. — Section of ovary of human embryo at sixth month : 
 c, external epithelial layer : 6, internal epithelial layer ; c, vas- 
 cular stroma of hilus ; d, mesovarinm. X 50.
 
 ANATOMY AND PHYSIOLOGY OF THE OVARY. 21 
 
 Archiv fiir Anatomie und Phys., 1872), to the effect that in the 
 new-born male a considerable proliferation of the epithelium of 
 the testicle is to be observed, together with the appearance in 
 that organ of round cellules similar to those from which sperma- 
 tozoa are derived in later life, and that these cellules disappear 
 shortly after birth, and are not found again till after pubert5^ 
 Similarly, De Sinety has not found developed ovarian follicles in 
 the years of childhood. 
 
 Haussman's observations, made upon eighty-four examina- 
 tions, completely substantiate De Sinety's conclusions. He found 
 premature development of the Graafian follicles in ten per cent, 
 of the ovaries examined, and he puts forward the important sug- 
 gestion that such a condition, by exhausting the stock of the 
 ova, or by prematurely discharging the activity of the ovaries, 
 may be a possible and hitherto unsuspected cause of amenor- 
 rhoea and sterility. 
 
 These observations cast a most interesting light upon the 
 parthenogenetic theory of the development of dermoid cysts 
 which originated with Ritchie, and which I have more com- 
 pletely elaborated in its appropriate chapter. 
 
 This ovarian activity seems to cease about the third month, 
 for after that time, though mature Graafian follicles can be 
 discovered by microscopic examination, they rarely are large 
 enough to be visible to the naked eye ; the bands of connective 
 tissue, with the fusiform cells or nuclei, increase in size, and the 
 tunica albuginea becomes more marked, so that by the seventh 
 month the ovary presents all the appearances which it has just 
 before puberty, and up to that time little else can be said of the 
 history of the gland. The only point which yet remains to be 
 settled, and for the settlement of which I have not come across 
 any evidence, is whether or not the premature Graafian folli- 
 cles ever rupture and discharge their nucleus into the peritoneal 
 cavity. There is some probability that they do, for reasons that 
 I shall give when speaking of wandering ova. 
 
 That most of the Graafian follicles thus produced — that, in 
 fact, a very large number of those produced in adult life, includ- 
 ing many which reach almost to maturity — die without rupturing 
 and discharging their egg-nucleus, is rendered certain by the 
 observations of every writer on the ovary, and I have already 
 indicated, from Balfour's writings, the possibilities of their ulti- 
 mate fate. 
 
 In a very remarkable paper by Dr. Creighton, of Cambridge, 
 published in the thirteenth volume of the Journal of Anatomy 
 and Physiology, that author sets himself to answer the question. 
 What becomes of Graafian follicles within which the ovum has
 
 22 
 
 DISEASES OF THE OVAllIES. 
 
 decayed ? The conclusions he comes to are not such as I can yet 
 see my way to accept, for among many hundreds of sections of 
 the ovaries of various animals in my possession I cannot find in 
 one indications of the structures which he describes, and the ap- 
 pearances he figures seem to me to be such as may arise from 
 
 F 
 
 
 
 \/oVSo»o*- 
 
 
 Fio. 15 (after Creighton).— Obsok-ioonce of Follicle!?, varions stage!?. 
 
 peculiarities in the preparation of the sections, and in their di- 
 rection. I can, for instance, easily accept the appearances at 
 A, B, C. and D, Fig. 15, as being sections, or slices off the top of a 
 Graafian follicle, and the drawing at G may similai-ly be a slice 
 out of a corpus luteum, as may also be the figure at F ; but I
 
 ANATOMY AXD PHYSIOLOGY OF THE OVARY. 23 
 
 must say that I completely fail to follow the reasoning which 
 would bring us to regard these forms as being homologous in 
 any way with the cortical substance of the supra-renal body fig- 
 ured at H. The paper itself is well worthy of perusal, as being- 
 full of information of undoubted value, and it may be that some 
 of Dr. Creighton's conclusions may receive a fuller acceptance 
 than I can give them ; wherefore, in order to draw attention to 
 them, I give the following summary of them, so far as they 
 deal with the fate of the decaying Graafian follicles : 
 
 ' ' The substance of the ovum, including vitellus, germinal 
 vesicle, and spot, disappears, and the zona or vitelline membrane 
 is found more or less empty and collapsed, as a strong, thick- 
 walled vesicle, of homogeneous structure, yellowish color, and 
 either ovoid in shape or somewhat folded. This tough mem- 
 brane evidently resists the influences that cause the vitellus and 
 germinal vesicle to disappear, and it is difficult to discover what 
 eventually becomes of it. At all events, in later stages of obso- 
 lescence of the Graafian follicle, it is no longer to be seen, and 
 the place of the follicle is marked only by the persisting belt of 
 follicular epithelium. The fate of the enclosing zone of epithe- 
 lium is in marked contrast to that of the ovum within it ; in pro- 
 portion as the latter shrivels and collapses, the former assumes 
 certain determinate and fixed characters, by which it may be 
 always easily recognized in the midst of the ovarian stroma. 
 The follicles drawn in Fig. 15 illustrate various stages in the pro- 
 cess of obsolescence. The follicle A exemplifies one of the most 
 fundamental changes. The ovum is wanting in the centre, and 
 the zone of follicular epithelium persists on one side : the point 
 that it is of importance to observe is the form of the epithelial 
 cells, 
 
 " The follicular epithelium does not, in the earlier periods of 
 life, present the usual characters of an epithelium ; the cells are 
 round and almost nuclear, or without cell-substance. Under or- 
 dinary methods of preparation, and under a moderate magnify- 
 ing power, they look like naked nuclei, just as the lymphoid 
 cells of a lymphatic gland do under the same circumstances. 
 As the follicle becomes riper the epithelium becomes more cylin- 
 drical ; it is at the two poles of the nucleus, and not uniformly 
 all round, that the protoplasm collects. This elongation of the 
 epithelium, which is never very pronounced in the follicle des- 
 tined to extrude its ovum in the ordinary course, becomes quite 
 obvious where the ovum decays within the cavity. The cells are 
 then seen (as in A, Fig. 15) to be greatly elongated, cylindrical 
 cells. In B and C the elongation of the epithelium, and the cor- 
 responding shrivelling of the ovum, are seen together ; at a, in
 
 24 DISEASES OF THE OVARIES. 
 
 the centre of each follicle, is the thick, structureless zona of the 
 ovum, which appears to be as if compressed or encroached upon 
 by the lengthening radial cells of the follicular epithelium. At 
 the same time the ends of the cylindrical cells that abut upon 
 the zona appear to have acquired a common bond of union, like 
 a basement-membrane. At D is represented a belt of follicular 
 epithelium, broken at the upper side, and without any traces of 
 the ovum within it. The follicle E exemplifies perhaps the most 
 common appearance of the belt of epithelium surviving after 
 the abortion and disappearance of the ovum ; the originally 
 circular belt (in section) has become almost straight, and the 
 shrivelled zona of the ovum lies toward its under surface and 
 almost clear of it. Tlie different forms of the belt of follicular 
 epithelium depend partly on the plane of section ; but there is 
 little doubt that the originally circular belt (as it appears in sec- 
 tion) unbends, and becomes a slightly curved cylinder, the shal- 
 low concavity of which corresponds to the original central space 
 where the ovum lay. At F is shown the belt of epithelium 
 doubled up, and with a stalk of connective tissue issuing from 
 its concavity. These various surviving conditions of the follicu- 
 lar epithelium appear to belong to follicles which had not become 
 greatly expanded ; the ovum had filled the central space exactly, 
 and there had been no development of liquor folliculi. There 
 are, however, aborted follicles of a much wider circuit, such as 
 that represented at G ; in this case the extensive belt of epithe- 
 lium is thrown into folds, and it is further noticeable that the 
 elongation of the epithelial cells is hardly perceptible, and that 
 there is no uniform basement line either on the outer or inner 
 surface of the belt. 
 
 " The peculiar cortical structures of the supra-renal bodies, 
 and their position relative to the rest of the organ, may be read- 
 ily made out in any good section of a well-prepared supra-renal 
 of the horse. Fig. 15, H, is a low-power view of such a section, 
 made perpendicular to the surface. The outermost stratum is a 
 zone of connective tissue of considerable thickness. Next to 
 that comes the zone of peculiar structures above referred to." 
 
 These peculiar cortical bodies of the supra-renals Dr. Creigh- 
 ton regards as homologous to the remains of Graafian follicles in 
 the ovary, from which the ova have not been discharged, but 
 have decayed. His conclusion is that "the morphological re- 
 semblance between the ovarian and the supra-renal structures is 
 not only close, but it is complete.'' I must, with all due defer- 
 ence to the work of an observer of so much distinction, say that, 
 so far as I can see, this position has yet to be proved.
 
 ANATOMY AND PHYSIOLOGY OF THE OVARY. 25 
 
 The Ovaries at Puberty. 
 
 What has already been said about the growth and ripening 
 of Graafian follicles before puberty constitutes one of the many 
 arguments in favor of the view that menstruation and ovulation 
 are wholly distinct processes, and abundant examples can be 
 given of them being carried on each independently of the other. 
 The statement made by Dr. Robert Barnes, that, if the ovaries 
 are extirpated or become atrophied, menstruation does not re- 
 appear, is not accurate ; and equally incorrect is his assertion 
 that the first ovular dehiscence corresponds with the first ap- 
 pearance of the menses. It is perfectly certain that ovulation is 
 by no means a periodic process, in the sense of being monthly, 
 and the fact that a periodic flow from the uterus is almost con- 
 fined to the human race is sufficient to show that it is not in the 
 ovaries that we have to look for the cause of this curious and 
 objectionable phenomenon, for which no one has ever yet sug- 
 gested a useful object. Where this cause does exist we do not 
 know, but it is quite certain that, as it continues for months, in 
 some cases, after the removal of both ovaries, it cannot be in 
 those glands. Nor is it in the uterus, for in most cases removal 
 of both ovaries arrests the function immediately; and in the 
 somewhat sho^t experience I have, up till now, had of the re- 
 moval of small ovaries, this has been always immediately ef- 
 fected, and completely, when I have been obliged to remove the 
 tubes as well. I have, therefore, a growing suspicion that we 
 shall find in the monthly movement of the tubes, or in their 
 structures, at any rate, the real source of the monthly discharge 
 from the uterus. 
 
 It is perfectly certain that no one has yet recorded one in- 
 stance in which the tube has been seen fastened on to the ovary 
 before or after the menstrual period of life, as it is during that 
 period. Yet ovulation goes on before puberty and after the cli- 
 macteric freely. The change in size and vascularity of the 
 tubes at puberty, and their diminution at the climacteric, and 
 the beginning and cessation of their movements, form the most 
 curious of all the remarkable features of those functional 
 changes, and are quite enough to show either that the tubes are 
 most markedly under the same periodic influence as that which 
 produces the menstrual flow, or that they themselves are its 
 cause. Finally, I have, during the last few years, had the op- 
 portunity of seeing the ovaries of a number of women, whose 
 abdominal cavities I have had to open for various conditions not 
 connected with diseased ovaries, and I have always found that
 
 26 DISEASES OF THE OVARIES. 
 
 during menstruation the tube is fastened, on the ovary, whether 
 there be a ripe follicle at the point of adhesion or not ; that both 
 tubes were generally fastened to their respective ovaries, though 
 in one ovary there may have been no appearance of a ripe ovi- 
 sac ; that I have very frequently seen an ovisac on the point of 
 bursting, or just burst, when the patient was midway between 
 two menstrual periods, this being a very frequent experience, as 
 I always selected, when I could, a time midway between the 
 periods for my operations, and in these cases I never found the 
 tube fastened on the ovary. Finally, I have removed, in two 
 cases, ovaries with the tubes fastened on them, during menstru- 
 ation, in none of which were there any ovisacs approaching 
 ripeness. 
 
 From these facts, and from others which will be detailed in 
 another chapter, I am persuaded that ovulation is wholly inde- 
 pendent of menstruation, and vice versa ; that the most impor- 
 tant feature of the menstrual period is the movement toward 
 the ovary of the trumpet-shaped opening of the tube, and the 
 grasi^ing of the gland by it ; that this grasping continues nearly 
 throughout the period of menstruation, and that it is only a mat- 
 ter of the chance of there being a ripe ovisac within the grasp of 
 one or other of the tubes that true ovulation— that is, the pas- 
 sage of the ovum into the uterus — takes place, and there is a 
 possibility of conception. If this be not so, it is quite impossible 
 to see how many married women escape having progenies im- 
 mensely numerous, seeing the numbers of ripe ova which are 
 produced, and the regularity of menstruation. If ovulation were 
 coincident with menstruation, the probabilities of a woman with 
 healthy organs, w^ho married at twenty, and ceased to menstruate 
 at forty-eight, would be to have eighteen children, instead of six, 
 which is her average as at present. Besides this, the number of 
 sterile women would be greatly diminished, and the increment of 
 the human population would exceed all management. Diminish- 
 ing our death-rate, or — to speak more accurately, as we should, 
 for we all must die — increasing the average death-age as we do, 
 by the abolition of wars and zymotic diseases, it is not difficult 
 to sec that some other agency must step in to aid civilization. 
 If we produced as many young as do t\ie lower animals, civili- 
 zation would be an impossibility ; the life-struggle would be so 
 keen that barbarism must prevail. The inevitable law of evolu- 
 tion has. therefore, secured some process — we do not yet know 
 what — by which the proportion of reproduction is limited, and 
 we are Malthusians despite ourselves. Look at the myriads 
 of young procreated by fish, only to serve for food to themselves 
 or birds. Between them and ourselves there is a change gradu-
 
 ANATOMY AND PHYSIOLOGY OF THE OVARY. 27 
 
 ally effected through the whole scheme, till we produce, as a 
 rule, one child at birth, occasionally two, and very rarely three 
 or four. These exceptions are clearly atavic. In some of the 
 higher apes there are signs of something like a menstrual pe- 
 riod, but as all such features in animal history become perverted 
 in confinement, we do not know much about them. But in the 
 lowest human races the signs of menstruation are very faint, 
 their labors are very easy, and their whole sexual history differ- 
 ent from that of the highly civilized races. It is abundantly 
 proved that, just as civilization (and I use the word in its most 
 literal sense) advances, so does the increment of sexual trouble 
 among women. The flexions, and atrophies, dysmenorrhoeas 
 and menorrhagias which affect town-bred women are compara- 
 tively unknown to their peasant sisters, and the healthily abun- 
 dant procreative power of a country laborer's wife is a frequent 
 source of envy to the patrician dame. 
 
 In all this menstruation is the chief factor, and I suspect the 
 want of synchronism between the embracement of the ovary by 
 the oviduct and the discharge of the ovum, perhaps also the in- 
 complete maturation of the ovum, will be found to be the most 
 important features of the change. 
 
 That menstruation is a new feature in sexual life, introduced 
 high up in the scheme, and has no analogy to the oestrus or rut 
 among the lower animals, is surely proved by the close reason- 
 ing of Arthur Farre (article Uterus: Encyclopaedia of Anat. and 
 Phys.). 
 
 The changes effected upon the general system by the acces- 
 sion of puberty do not concern us here, and therefore I shall 
 limit myself to those concerning the ovary and oviduct, and for 
 the observations on which my conclusions are based I am in- 
 debted to my own researches entirely. 
 
 The structure of the ovary does not seem to be changed in 
 the least by the accession of puberty, save in its vascular ar- 
 rangements. Before puberty the mesovarium is thin and trans- 
 parent, occupied by arteries and veins probably as numerous as 
 they are afterward, but straighter and much smaller, the veins 
 especially being but slightly pronounced, and quite different 
 from the appearance of a bag of purple worms which they often 
 have in after-life. After puberty these vessels become convolu- 
 ted and distended. The ovary itself is slightly increased in size, 
 but no very marked alteration in this respect is to be made out, 
 a matter upon which Henning's measurements are confirmatory. 
 The chief alteration consists in a greater size of the arterioles, a 
 thickening of their muscular coat, and their assumption of a heli- 
 coid form, which I have been whollv unable to recognize in the
 
 28 DISEASES OF THE OVARIES. 
 
 ovary prior to puberty. This, however, is an extremely difficult 
 point to decide, for I greatly suspect that this helicoid arrange- 
 ment of the arteries in the ovary, and perhaps in other glands, 
 may be due to the degree of tension at which they are injected. 
 It is at best difficult to make out, for the thickness of a transpa- 
 rent section seems but rarely to contain a complete coil, and 
 however numerous and complete the coils may be, it is not diffi- 
 cult to see that the method of examination is such that they may 
 be missed. I have, however, so often seen sections of such heli- 
 ces in ovaries after puberty, and especially in the glands of mul- 
 tiparous women — though I have often entirely failed to find 
 indications of them in similar ovaries — that I cannot help think- 
 ing that there is some reason in their presence, which will be 
 found to affect the condition resembling the engorgement of 
 erectile tissue which the ovary assumes during menstruation, 
 but more particularly during pregnancy (v. Homing). In nor- 
 mally erectile tissue these helices have been regarded as the 
 intrinsic mechanism of the engorgement — a view which I have 
 never been able to accept, for I have never realized that they 
 can be more than a means of permitting the elongation of the 
 vessel when the diameter of the organ is increased. When it is 
 empty, they are coiled up like the slack of a rope, and therefore 
 it is that I have already said that the helices present in a mi- 
 croscopical section will greatly depend on the tension of the in- 
 jection. If the organ is greatly distended, the arteries will be 
 straight. If slightly distended, they will or may be coiled, and 
 I think it quite possible that my not having found them in ova- 
 ries before puberty may be due to the fact that the tissue of the 
 gland is then more easily affected by distention, and that their 
 absence may be from faulty preparation. Still it is likely that 
 the altered hsemic condition of the gland after puberty may pro- 
 duce them. 
 
 To inject an ovary before puberty is not an easy task, and to 
 get the opportunity of examining one is rare. I have therefore 
 not been able to get perfectly satisfactory results as to the con- 
 dition of the vascular supply of the ovisacs. "What evidence I 
 have, however, shows that there is little difference in it from 
 what is found after puberty beyond this, that it is possible the 
 vessels are all larger, though upon this point I can say nothing 
 positively. But of this I am certain, that all the phenomena 
 which occur in the rupture of an ovisac and the closure and heal- 
 ing of the cavity are in common occurrence before puberty, 
 and that the characteristic arrangement of capillaries in what is 
 called the corpus luteum can be seen long before the occurrence 
 of menstruation.
 
 ANATOMY AND PHYSIOLOGY OF THE OVARY. 29 
 
 Spiegelberg says {Monatschrnft fiir Gehurtskunde, 1867) that 
 he has seen the inner layer of the ovisac distinctly marked off, 
 and possessed of a yellow color, as early as the second year of 
 life. I certainly have seen, in one ovary of the ninth year, an 
 appearance which I could not have told from an adult coi'pus 
 luteum of about fifteen days after the rupture of the ovisac. 
 
 In fact, the whole process of ovulation goes on before puberty, 
 and the only difference then made is the important addition of 
 the carrying the ovum into the uterus, and the possibility of its 
 being there impregnated. These additions, however, do not 
 affect the function of the ovary, which was complete before 
 that, as is proved by the parthenogenetic production of ovarian 
 tumors, and, in comparative anatomy, by complete partheno- 
 genesis. 
 
 It will serve our purpose, then, if we now complete the de- 
 scription of the normal anatomy of the ovary by detailing the 
 history of an ovisac after its formation. 
 
 The mature human ovum measures y^„- of an inch in diam- 
 eter, and its germinal vesicle probably about ^i^- of an inch, 
 though its exact measurement, free from yolk-substance, has 
 probably not yet been made. The nucleolus, or germinal spot, 
 is about g-oVo^ of an inch in diameter. The ovum lies at first 
 centrally in the ovisac, or Graafian vesicle, but in the ripening 
 of the latter the ovum moves toward the periphery of the sac, 
 and is always to be found close to the surface of the ovary when 
 the sac ultimately bursts. This movement is variously explained, 
 but the more certain processes are, the formation of a liquor fol- 
 liculi by the solution of the epithelium, especially in the outer 
 part of the sac, and the effusion of the fluid on the other side of 
 the ovum, pushing the discus proJigerus against the thinned wall. 
 This wall is of two layers, the outer being formed of the stroma 
 of the ovary and the peritoneum, and the inner, at first non- 
 vascular, from the follicular epithelium. This inner layer rapidly 
 thickens, becomes vascular, and takes on a distinct yellow color, 
 long before the follicle is ready to burst. It has been called the 
 memhrana granulosa, but this extra name does no more than 
 describe one of its characters, and leads to confusion. It is the 
 epithelial layer, and it thickens everywhere but at that point 
 where the ovum lies in contact with it, ready to issue forth at 
 the moment of rupture, and the ovum is lightly retained in its 
 place by a cellular attachment to this layer at the indefinite 
 margin of the discus proligerus. By the time the ovisac is ready 
 for rupture this layer has become very thick and vascular, and 
 is composed entirely of large, round, and rapidly growing epi- 
 thelial cells. The vascularity of the walls of the ovisac is most
 
 30 DISEASES OF THE OVARIES. 
 
 marked at the point of impending rupture, and its vessels are 
 visible to the naked eye on the surface of the ovary. The rup- 
 ture takes place at last, and the ovum escapes either into the 
 peritoneal cavity, where it perishes, save in exceptional cases, 
 or into the pavilion of the oviduct, whence it is conducted to the 
 uterus. I believe that the ovum falls into and perishes in the 
 peritoneal cavity in by far the greater number of cases, and that 
 the passage of it into the uterus occurs only in a small minority 
 of the ova produced. The vessels ruptured in the act of the 
 escape of the ovum bleed slightly, and this hemorrhage occupies 
 the emptied cavity, and must, in many cases, along Avith the 
 liquor foUiculi, also pass into the peritoneal cavity. I have re- 
 peatedly seen a clot hanging from a ruptured ovisac into the 
 cavity of the peritoneum, and on one occasion I saw the follicle 
 rupture before I had touched the ovary, which lay exposed on a 
 uterine tumor. Spiegelberg (loc. cit.) tells us that in women this 
 hemorrhage is very insignificant, as it is also in the cow. In 
 the mare and sheep it is entirely absent, and is most marked in 
 the sow. I have seen nothing to make me believe that in wo- 
 men it is ever so severe as to be pathological, but I can easily 
 imagine that sometimes it may really be so, and may explain 
 those rare and mysterious cases of recurrent pelvic hsematocele 
 of limited extent, of which I have lately seen a most curious in- 
 stance in the wife of one of my professional brethren. 
 
 After the rupture the follicle collapses, and the thickened 
 inner coat is thrown into a series of convolutions strikingly re- 
 sembling those of the brain, tliough I am by no means sure 
 that these convolutions are not indicated before the rupture 
 occurs. I have seen them in an unruptured ovisac before pu- 
 berty, but as the ovary had been pickled in chromic acid for 
 section-cutting, they may have been produced by preparation. 
 I have also seen them in an unripe sac opened immediately after 
 removal of the ovary. Here again they may have been pro- 
 duced instantaneously by the relief of tension. On a favorable 
 opportunity I shall freeze a fresh ovar}^ before cutting it, and 
 settle this interesting question. 
 
 The rent in the ovisac soon heals, and the cavity is again 
 closed, with a small clot in its centre, and this clot was formerly 
 accredited as the source of all the phenomena of the much-dis- 
 cussed corpus luteum. It deserves no such distinction, and it 
 soon becomes decolorized and is absorbed, so that the points 
 of the convolutions come into contact, ultimately coalesce, and 
 finally form the stellate cicatrix which marks for a long time 
 the site of the ovisac. The capillaries of the inner or yellow 
 «oat are very regular, and, in a well-injected section, resemble
 
 AXATOMY AND PHYSIOLOGY OF THE OVAKY. 31 
 
 A'-ery much those of a vilhis of intestine. They spring from a 
 small helicoid arteriole, having very thick muscular walls and 
 two layers of fibres exactly like the arterioles of the kidney, in 
 the outer wall of the ovisac. This arteriole breaks up at once 
 into a ramifying mesh work, which seems to lie between the two 
 coats of the sac, and which probably provides the vessels seen 
 on the outer surface of the ovary at the point of rupture. From 
 this meshwork straight wide capillaries run down in the centre 
 of each lol>e to its apex, giving off small branches to each side. 
 At the apex of each villus or lobe (from a section it is quite im- 
 possible to say which of these words is correct, though I think 
 lohe would be the proper one) comes a vein which runs down be- 
 tween the lobes to the point of vascular origin, and between 
 these interlobular veins and the intralobular arteries there are 
 universal systems of capillary communication. Along the free 
 margins of the lobe seems to run a system of communicating 
 canals, and this it is which causes me to regard this second 
 system of vessels as the veins, together with the fact that I can- 
 not make out that they have thickened muscular walls. In the 
 absence of a successful double injection, which I have never 
 accomplished, this interpretation of these structures may be in- 
 accurate. Within the meshes of vessels are seen the regular 
 round epithelial cells, so arranged as to give a general contour 
 of convolution, and in the cavity are the altered blood-corpuscles. 
 
 The lack of greater precision in this description is to be ex- 
 plained by the fact that the preparation of an ovary fortunate i.i 
 all respects is very difficult, and I have but seldom succeeded, 
 and that for some years now I have been too much engaged with 
 practice to follow up the research, which requires abundant and 
 uninterrupted leisure. 
 
 The disappearance of the red color of the central clot is the 
 first change observed in the contracting cavity, and with this 
 the whole forms a yellow convoluted patch. As it contracts the 
 yellow color disappears, this change being effected in about two 
 months in the non-pregnant state. The microscopic characters 
 of the change consist in the disappearance of the cells, said to 
 be brought about by fatty degeneration, though of this I have 
 seen no evidence. This absorption is accompanied by the shriv- 
 elling of the blood-vessels and their final disappearance, so that, 
 in eight or ten months, nothing is left but a star-shaped cicatrix 
 extending into the substance of the ovary; but this probably in 
 time entirely disappears in a young ovary. After impregnation 
 these changes are effected much more slowly, owing to the al- 
 tered nutrition of the whole organs, so that the yellow color may 
 not disappear for twelve or fourteen months (Farre), and the
 
 32 DISEASES OF THE OVAKIES. 
 
 shrinkage of the cicatrix may take two years to be effected. It 
 by no means follows, however, that an ovisac thus delayed in 
 disappearance has been the seat of an ovum which has been 
 fertilized, for I have seen three such corpora lutea in the ovary 
 of a woman who had been confined only seven months before 
 my operation, of one child — her only one. Farre says that during- 
 pregnancy in such ruptured ovisac there is a special increase in 
 the thickness of the epithelial lining, and a larger deposit of oil- 
 granules, but I have failed to get confirmation of his statement. 
 During pregnancy, and for some time after it, the ovaries are 
 especially increased in size by enlargement of their vessels, and 
 so are the contained corpora lutea. The distinguished author 
 just quoted says : "The irue corpus luteum is the follicle in its 
 largest condition of growth, as it appears after impregnation ; 
 whilst in all other conditions, when it has not been stimulated 
 to full growth by impregnation, and whether before or after rup- 
 ture, it has been called a false cojpiis luteum, so long as it pos- 
 sesses the yellow color." The differences are therefore only 
 questions of degree, and cease to give any special characters 
 long before other indications of pregnancy have passed away. 
 To elevate this structure, therefore, into a medico-legal impor- 
 tance is not to be justified ; and after a very extensive acquaint- 
 ance with ovaries I would not venture to give an opinion, from 
 any number of corpora lutea, as to whether they indicated past 
 pregnancy or not. The great battle on this point has been sin- 
 gularly barren of results. 
 
 At puberty a very marked change is effected in the appear- 
 ance and functions of the Fallopian tube or oviduct. Before 
 puberty the tube is small and straight, and the size of the fim- 
 brise insignificant. When injected, its vascularity is not a very 
 leading feature, and certainly presents a most marked difference 
 to the peculiarly abundant blood-supply visible in its large- 
 meshed network of capillaries in adult life. The muscular fibres 
 of the fimbriae are also very ill-defined before puberty, and no 
 evidence is offered by any one that it ever makes any kind of 
 functional movement. In adult life, as every one knows, one or 
 both tubes seek their respective ovaries, and become attached 
 to them for a time, which I believe to be concurrent with men- 
 struation, by cellular adhesion. Permanent adhesion, the result 
 of peri-oophoritis, is often met with in women who have led 
 lives of prostitution, and in them a sort of permanent metrorrha- 
 gia is by no means rare. 
 
 In the tube of a girl under the age of puberty I have been un- 
 able to find any of the ciliated epithelium which afterward lines it. 
 
 My conclusions are, therefore, that the changes in the ovary
 
 ANATOMY AND PHYSIOLOGY OF THE OVAEY. 
 
 33 
 
 at puberty are entirely vascular ; that in the tube they are vas- 
 cular, muscular, and epithelial. But that the most important 
 change of all is the functional movement of the tube, the ab- 
 sence of which alone makes pregnancy before puberty impossi- 
 ble. Otherwise I do not believe that puberty has much to do 
 with procreative power in women. 
 
 During the climacteric period a series of changes are effected 
 in the sexual apparatus which make themselves felt throughout 
 the system, but the results of which are not apparent in the 
 structures themselves for some considerable time after the meno- 
 pause. Ritchie and others have shown conclusively that the 
 formation of true ova goes on long after this event, and I have 
 seen in ovaries of very old women structures which I could not 
 have decided as being in any way different from those seen in 
 the ovaries of women at the prime of life. It is quite certain that 
 the growth of ova persists till the end of life, though with ad- 
 vancing age it gets feebler, the cells become less numerous and 
 less mature. The ovaries, however, continue to be the seat of 
 cell-growth, and pathological cysts are formed in them some- 
 times even at the very extreme of old age, at a time when oper- 
 ative interference becomes hopeless on account of the age of the 
 patient. The general atrophy which accompanies senility affects, 
 
 Fig. 16. — Ovary at menopause. (Arthur Farre.) 
 
 Fig. 17. — Senile ovary. (Arthur Farre.) 
 
 of course, the ovaries, and late in life they are usually small and 
 shrivelled, abundantly marked by scars, and having all the ap- 
 pearances of having been worked out. But even then they ex- 
 hibit traces of all their old products, and I have seen an ovary 
 from the body of a woman nearly seventy years of age, which 
 it would have been impossible to say might not have been re- 
 moved from the body of a woman of thirty. 
 
 The changes which are most apparent are those effected in 
 the uterus and tubes. These structures rapidly diminish in size, 
 and the tubes are straightened and cease their movements. 
 Here we have further proof that ovulation and menstruation are 
 wholly independent, that menstruation is not dependent on the 
 ovaries or on ovulation. I think also that there is additional 
 evidence in favor of the view to which I am inclined — that men- 
 struation is wholly a function of the Fallopian tubes.
 
 34 DISEASES OF THE OVARIES. 
 
 The ovary, then, is simply a gland, developed as other glands, 
 and formed of similar elements ; its peculiarity is, that its cell- 
 nuclei have special powers during a certain time of life ; and 
 this simplification of its physiology does much to simplify its 
 pathology. 
 
 A few sentences from Balfour, concerning the phenomena 
 observed in the maturation and impregnation of the ovum, may 
 here be fittingly introduced. I take them verbatim, as it is a 
 point upon which I have made no research. 
 
 " Every ovum, as it approaches maturity, is found to be com- 
 posed of (1) a protoplasmic body or vitellus, usually containing 
 yolk-spherules in suspension ; (2) of a germinal vesicle or nu- 
 cleus, containing (3) one or more germinal spots or nucleoli. 
 The germinal vesicle, at its full development, has a more or less 
 spherical shape, and is enveloped by a distinct membrane. Its 
 contents are for the most part fluid, but may be more or less 
 granular. Their most characteristic component is, however, a 
 protoplasmic network, which stretches from the germinal spot 
 to the investing membrane ; but especially concentrated around 
 the former germinal spot is a nearly homogeneous body, with 
 frequently one or more vacuoles, occupying one of the eccentric 
 positions within the germinal vesicle, and it is usually rendered 
 very conspicuous by its high refrangibility, is sometimes capable 
 of amoeboid movements (Auerbach and Hertwig), and is more 
 solid and more strongly tinged by coloring agents than the re- 
 maining constituents of the germinal vesicle. 
 
 ''During the further maturation of the ovum the germinal 
 vesicle moves toward the surface of the e^^, its membrane be- 
 comes absorbed, and it is metamorphosed into a spindle-shaped 
 body, this being done at the expense of the germinal spot. One 
 end of this spindle enters a protoplasmic prominence at the sur- 
 face of the egg, the spindle itself dividing then into two, one 
 half remaining in the Qgg, the other in the prominence. This 
 prominence, at the same time, becomes nearly constricted off 
 from the Qgg as a polar cell, and a second polar cell is similarly 
 formed. That part of the spindle remaining in the egg is con- 
 verted into a nucleus — the female pronucleus — and this is moved 
 toward the centre of the egg. On the entrance of one sperma- 
 tozoon into the egg the head of the sperm is converted into an- 
 other nucleus — the male pronucleus. Around this latter radial 
 striae immediately appear, and these travel toward the female 
 pronucleus. The fusion of the two pronuclei, through the con- 
 necting striae, form the first segmentation nucleus."
 
 CHAPTER II. 
 
 EERORS OF DEVELOPMENT AND DISPLACEMENTS OF THE OVA- 
 RIES AND OVIDUCTS: SALPINGITIS, HYDROSALPINX, PYO- 
 SALPINX, HiEMATO-SALPINX, AND FALLOPIAN PREGNANCY. 
 
 Uterus unicornis mit Verlaufendes Ovariumslinks. Beigel. Archiv f iir Gynaekolo- 
 gie. V. XI. 
 
 Doppelseitige Hernia ovarialis inguin. Werth. Archiv f iir G-ynaekologie. V. XII. 
 1877. 
 
 Inguinal Hernie des linken Uteruskorpers. Extirpation desselben und des linken Ova- 
 rium. Leopold. Archiv fiir Gynaekologie. V. XIV. 
 
 Hyperaesthesie des Ovarium. Geissler. Schmidt's Jahrbuch. V. 172. 
 
 Adhiision und Prolapsus des Ovarium. Cleveland. Schmidt's Jahrbuch. V. 176. 
 
 Graviditas ovarialis und tubo-ovarica. Spiegelberg. Schmidt's Jahrbuch. V. 182. 
 
 Ein Fall von Androgynie des richter Eierstocks. LiTTEN and ViRCUow. Virchow's 
 Archives. V. 70. 
 
 Ovarien Prolaps. Stocks. Centralblatt f. Chir. V. I. 
 
 Ovarialheruie. Weinlechner and Ballerat. Cent. f. Chir., V. 5, and Wiener 
 med. Wochenschrift. 1877. 
 
 Prolapsus of the Ovaries. Munde. Med. Times and Gazette, January, 1880. 
 
 Absence Probables des Ovaires. Rqeinstadler. Ann. de Gyn. V. 13. 
 
 Prolapsus of the Left Ovary in a Case of Retroversion. American Journal of Obstet- 
 rics. Vol. X. 
 
 Atrophy of the Ovaries in Insanity. DoRAN. Obstet. Journal. December, 1879. 
 
 Congenital Double Inguino-Ovarian Hernia. Chambers. Obstet. Journal, December, 
 1879. 
 
 Hernia of Ovaries Successfully Operated upon. Works of Percival Pott, by Earl. Vol. 
 IL, p. 210. 
 
 Recherches sur la hernie de I'ovaire. L. C. Deneux. Paris, 1813. 
 
 Des hernies de I'ovaire. PuECn. Gazette obstotricale de Paris. 1875. 
 
 Hernia Ovarialis. Englisch. Wiener med. Wochens. Jahrbuch. 1871. 
 
 Parthenogenetic Development of Cysts of Ovary. Tait. Brit. Med. Journal, Janu- 
 ary 3, 1880. 
 
 Prolapse of Ovaries. Atthill. Med. Press, December 10, 1880. 
 
 Infantile Uterus and Mmute Ovarian Cysts. Marey. American Journal of Obstet- 
 rics, April, 1880. 
 
 Rudimentary Fallopian Tubes and Ovaries. Bowen. Med. Record, New York, June 
 5, 1880. 
 
 Prolapsus of Ovary Relieved by Pessary. Lyman. Boston Med. and Surgical Jour- 
 nal, April 1, 188 ). 
 
 HyperEesthesia of Ovary. Barlow. Medical Times and Gazette. 1877. 
 
 Prolapse of Ovaries. Skene. American Journal of Obstetrics, April, 1879.
 
 36 DISEASES OF THE OVARIES. 
 
 Hernia of Ovary. Bird. Guy's Hospital Reports, 1878. 
 
 Congenital Hernia ot Both Ovaries. VV. Makeig Jones. Brifc. Med. Journal, Sep- 
 tember, 1877. 
 
 Prolapse of the Ovaries. Pkop. Goodell. Lessons in Gynecology. Philadelphia, 
 1880. 
 
 Open Fallopian Tube. D. Mathews Duncan. British Medical Journal, March, 1881. 
 
 Note on the Diagnosis of Extra-Uterine Pregnancy. Lawson Tait. Trans. Obstet. 
 Soc. , London, 1873. 
 
 Des gropsesses extra-ut'rines. Tii. Keller. Paris, 1873. 
 
 Extra-Uterine Pregnancy. Lloyd Roberts. London, 1878. 
 
 Grossesses extra-uterines. Ditguet. Annalea de Gynccologie. 1874. 
 
 Memoir on Extra-Uterine Gestation. Wm. Campbell. Edinburgh, 1842. 
 
 Extra-Uterine Pregnancy. John S. Parry. London, 187G. 
 
 Though congenital defects of the ovaries and oviducts are 
 of comparatively rare occurrence, yet, as might be expected, in 
 the case of a gland which performs functions so important as 
 those of the ovary, and whose functions are of universal exist- 
 ence, complete absence of the gland is extremely rare. So far 
 as I have been able to find, there are only three preparations in 
 this country indicating complete congenital absence of the ova- 
 ries. Of these, two exist in the cases of malformed foetuses, in 
 which there may be said to be an almost complete absence of the 
 whole genital apparatus. The third occurred in the case of a 
 girl who died at twenty, without ever having menstruated ; and 
 in that case also the whole genital apparatus was extremely 
 defective. 
 
 Like every other organ in the body, the ovary is liable to 
 arrests of development, but from what cause or causes these 
 arrests arise, it is not very easy to say. This is a question which 
 has not yet received sufficiently careful attention ; but be the 
 cause what it may, it is quite certain that whatever arrests the 
 development of the ovaries equally affects the development of 
 the whole of the genital organs. In the case of the aves, both 
 ovaries and oviducts are equally developed in the embryo, but 
 on one side an atrophy occurs early in life which leads to a total 
 suppression of the organs on that side, and the sexual functions 
 are carried on by the left side only. What the explanation of 
 this, and what its cause, is wholly unknown. I am not aware 
 that any similar condition is known to be of even occasional oc- 
 currence in woman. I have found only one reference to the ex- 
 istence of a unilateral arrangement of mature organs, quoted 
 by Busch from Chaussier. in the case of a woman who had borne 
 ten children, and who, on post-mortem examination, was found 
 to have an entire absence of the tube and ovary of the left side, 
 and apparently an absence of the corresponding side of the 
 uterus. When the ovaries are defective it is almost invariably
 
 ERROKS OF DEVELOPMENT OF OVARIES AND OVIDUCTS. 37 
 
 the case that the other organs are equally ill-developed; but 
 what is the order of the occurrence is not in any way clear. 
 
 I have already pointed out at some length, and I shall dis- 
 cuss in detail in a subsequent chapter, the effects which certain 
 diseases of the zymotic type have upon the sexual organs— more 
 particularly scarlet fever. As this disease is peculiarly incident 
 to childhood, I have a very strong impression that a large num- 
 ber of the cases of incompletely developed sexual organs in wo- 
 men arise from the effects of this disease in childhood. In such 
 cases we find that the occurrence of menstruation is unduly 
 protracted, or it may not be apparent at all ; that, at the time 
 when the disturbance should occur, a number of vague symp- 
 toms make their appearance, sometimes trifling, at otlier times 
 extremely serious. If, under these circumstances, the patient 
 be examined, the uterus will be found to be infantile in size, an- 
 teflected ; and if a post-mortem examination should be made, 
 the ovaries will be found small, possibly somewhat puckered, 
 the mesovarium but slightly indicated, the tubes extremely 
 small ; and should the patient have reached mature life without 
 the occurrence of menstruation, the organs will be found to pre- 
 sent all the appearances of those of a child between five and ten 
 years of age. 
 
 In such extreme cases the development of the whole sexual 
 apparatus is generally imperfect, the sexual appetite is in abey- 
 ance, and there may be comparatively little suffering after the 
 first few months, during w-hich an effort seems to be made by the 
 system to establish the change. This is provided epilepsy does not 
 supervene, which is, however, only too common an accompani- 
 ment of arrested sexual development in women. Women who 
 are thus affected have frequently an absence of those external 
 peculiarities of their sex evident in roundness of form, a pro- 
 nonce bust, smooth and hairless skin, and highly pitched voice ; 
 and they often partake, in some slight degree, of the characters 
 of the opposite sex, especially in the growth of straggling tufts 
 of hair on the upper lip and on the chin in a line with the canine 
 and premolar teeth. 
 
 A greater number of cases have the arrest at a later stage, 
 and in them menstruation is established, after much difficulty 
 and suffering, between sixteen and nineteen years of age, and, 
 though it may last with fair regularity, but deficient quantity, 
 for four or five years, it then ceases completely. In many of 
 these cases, however, if marriage should occur during the time 
 that menstruation is in action, and if the patient should be for- 
 tunate enough to become pregnant, a cure may result ; that is, 
 her periods will become more abundant, and her suffering less ;
 
 38 DISEASES OF THE OVARIES. 
 
 her health will be improved, and she may go on menstruating 
 for many years, and may even have a number of children. Even 
 without the occurrence of pregnancy, marriage often establishes 
 the health of a woman afflicted with arrest of ovarian develop- 
 ment. 
 
 The great bulk of cases of this kind are those which are 
 afflicted to a less degree, but whose sufferings are nearly always 
 sufficient to require medical assistance ; and it is a singular fact 
 that a very large percentage of the patients are found to be 
 women of splendid physical development, who, to any but one 
 well acquainted with such cases, look the most likely to possess 
 capacity for procreation. In these women menstruation is estab- 
 lished later than the normal time by a few months or a year or 
 two. They have, at first, irregular times and much pain, but 
 after a while the flow is established with normal quantity and 
 regularity, and with but little suffering. In this way they go 
 on for eight or ten years, and, if they marry in the interval, their 
 menstrual career may run an ordinary course. If they remain 
 single, however, they begin to suffer from ovarian dysmenor- 
 rhcea between twenty-five and thirty, and, after about ten years' 
 suffering, they undergo a premature climacteric change. It is 
 also noticeable in these women that their menstrual function is 
 suspended on slight provocation. Any chronic disease — even of 
 an unimportant nature — any occupation which necessitates an 
 overstrain on their system, mental anxiety, or sudden fright, 
 will check their menstruation for months or years, or perhaps 
 forever. In fact, this slight excess of functional power which 
 the ovary became possessed of at their puberty is readily and 
 soon exhausted, and its extruded cells, on slight provocation, 
 assume an immature form, and the systemic conditions become 
 correlated. In fact, in such cases of amenorrhoea, and similarly 
 to a less extent in those of dysmenorrhoea, there is a temporary 
 resumption of the infantile condition of the ovarian functions ; 
 or it may be a complete and premature assumption of their 
 senility. The amenorrhoea of pregnancy and lactation are also 
 partial resumptions of the infantile condition. This view has 
 been admirably expressed by Dr. Charles Ritchie: "In early 
 infancy, extreme old age, and long-continued organic disease, 
 the ova are minute, transparent, and structureless ; and in ad- 
 vanced childhood, soon after the critical age, and during preg- 
 nancy and lactation, they are more or less organized, larger, and 
 in the latter stage are often so well matured that about one-third 
 of the renewed pregnancies of married women take place while 
 they nurse." 
 
 In these slighter cases of this kind of dysmenorrhoea the uterus
 
 ERRORS OF DEVELOPMENT OF OVARIES AND OVIDUCTS. 39 
 
 is generally normally developed, and it is frequently so in some 
 of the most severe cases. There is a converse condition where 
 the uterus is infantile and the ovaries normal, much more rare 
 and far more severe in its symptoms. 
 
 In all such cases the general symptoms are pretty constant 
 and distinctive. Besides the menstrual irregularities and defi- 
 ciency, there is almost always a persistent, sickening, and well- 
 marked pain, occurring in the less severe cases only at the men- 
 strual periods, but in others being seldom absent, and always 
 greatly increased at the periods. It originates in the ovarian 
 region, and shoots down the thigh, often also down the leg and 
 around to the back. There is also often present, especially on 
 the accession of atrophy, the peculiar submammary pain of 
 ovarian disease, generally felt in the left side only. Headache, 
 nausea, or even sickness and great general discomfort, are al- 
 ways present more or less. 
 
 In the milder cases treatment is generally successful in miti- 
 gating the sufferings, and often the ovary may be made, even 
 in some very well marked cases of arrested development, to ful- 
 fil its functions completely. First of all therapeutic remedies 
 there stands iron, which will be found in such cases to be of 
 great use, even though there should be no general indications 
 for its employment. There can be no doubt that many forms of 
 this remedy have a specific power over the sexual organs, male 
 and female ; for, in a case of chronic metritis or subinvolution, 
 smart hemorrhage may be induced by large doses of iron. In 
 ovarian and tubal dysmenorrhoea it is best given during the inter- 
 menstrual periods in small doses, one to five drops of the liquor 
 ferri perchloridi, well diluted, and increased suddenly to fifteen 
 or twenty for a day or two previous to and during the menstrual 
 flow; or, quite as good, is the substitution of an iron and aloes pill 
 for this large dose, there being few better combinations in the 
 pharmacopoeia than that old-fashioned remedy. Hot hip-baths 
 and leeches to the perineum at the period are often useful addi- 
 tions, with an occasional blister on the sacrum. To such as this, 
 the treatment of delayed or difficult menstruation at puberty, 
 due to inefficient ovarian development, must be confined ; for 
 the other means are only allowable in very obstinate cases, after 
 the patient has been married, or when there are indications of 
 premature ovarian atrophy. Marriage is, perhaps, the most 
 efficient remedy, and one we may, under certain circumstances, 
 recommend ; for, even if the patients should not have children, 
 they will have better health, and they may even become preg- 
 nant if they marry early enough and are not mismanaged. 
 
 The last and most powerful aid is mechanical irritation of the
 
 40 DISEASES OF THE OVARIES. 
 
 uterus ; but, as it is not free from risk, and therefore requires 
 careful use, it is not always to be recommended. It is, besides, 
 in the class of cases where the uterus is most at fault that it is 
 least risky and most serviceable. The method of irritation I 
 generally employ, as the most convenient and least troublesome, 
 is the insertion of Simpson's galvanic pessary. This instrument 
 has by some writers been very much decried, but I think by 
 those only who seem to have used it indiscriminately, and with- 
 out reference to a proper selection of cases. 
 
 The irritation set up by the presence of a galvanic stem in 
 the uterus is communicated indirectly to the ovaries in a man- 
 ner that is not as yet explicable, but that it has an influence is 
 beyond doubt, and, if it remain within bounds, it is in a large 
 number of cases beneficial. A large experience has shown me 
 that it is only in occasional instances that the stem cannot be 
 borne, and that, if carefully watched during the first few weeks 
 of its use, these cases are easily eliminated. In a case where I 
 have been led to regard the use of the stem as advisable, I 
 always begin with a small size, and after this has been worn for 
 two or three months I change it for a larger one. For the first 
 week after its introduction it is not unusual for the galvanic 
 stem to give rise to considerable discomfort and even positive 
 pain ; but this usually passes off if the patient keeps her bed for 
 a few days, and there is no further trouble save from the leu- 
 corrhoeal discharge, which is a part of the process. The action 
 of the stem is not purely mechanical, as has been stated ; for, 
 very soon after its insertion, the zinc becomes coated with an 
 albuminous deposit, from which the copper is free, and the zinc 
 becomes corroded. It is certain, therefore, that there is a gal- 
 vanic action set up, and the stimulating effects are due partly 
 to this, and partly to the interior of the uterus being constantly 
 bathed in a weak solution of chloride of zinc. However pro- 
 duced, it is certain that the uterus rapidly enlarges under the 
 action, and there is every reason to believe that the ovaries take 
 part in the increased activity. If once the uterus becomes ac- 
 customed to the presence of the galvanic stem, it may be worn 
 for many months, and the longer it is retained the more perma- 
 nent will be the benefit; but if, after a trial of a few months — say 
 four or five, there is no apparent alteration for the better, the 
 attempt should be given up, and the case considered as hopeless. 
 
 In a very large number of cases of incompletely developed 
 ovaries another remnant of infantile life is met with in an exag- 
 geration of the normal curve of the uterus, amounting some- 
 times to complete anteflexion, and in this class of cases the ge^- 
 vanic stem is especially serviceable.
 
 ERRORS OF DEVELOPMENT OF OVARIES AND OVIDUCTS. 41 
 
 The results of my attempts to arrest premature atrophy of 
 the ovary from any cause, when once begun, have been far from 
 satisfactory ; and this has been more especially the case when 
 that atrophy has been due to a constitutional disease, such as 
 tubercle. Sir James Simpson had a belief that the pretubercular 
 amenorrhcea, so often seen in young women, was a cause of the 
 subsequent disease ; and he therefore directed his attention to 
 the restoration of the utero-ovarian function as a means of 
 treatment or prevention of the consumption. From the views 
 previously expressed, it will easily be seen that I consider his 
 theory to be based on error, though in some cases his treatment 
 would seem to have been successful ; but how much of his suc- 
 cess was due to local and how much to general treatment cannot 
 now be determined. It is not, however, a practice likely to 
 meet with many followers. 
 
 It will be seen, therefore, that not only is the ovary extremely 
 liable to be arrested in its growth from childhood to adolescence, 
 but it is also liable to have induced upon it a condition of prema- 
 ture senility. It is unlike most of the glands of the body in that 
 it has its functions limited to a particular period of life, or at 
 least the period during which these functions are complete is so 
 limited — and therefore it seems possible, and to be of not unfre- 
 quent occurrence, that the period of complete functional ac- 
 tivity is very materially shortened. This I think we shall after- 
 ward see to be by no means unusual after first confinements, 
 more particularly after miscarriages which occur early in sexual 
 life ; for the number of women who come under my care is largo 
 in whom the history is uniformly given of an attack of pelvic 
 inflammation after the first pregnancy, and who have suffered 
 from distress from that date, and have never again become 
 pregnant. The explanation of this will be found in the adhe- 
 sions formed by the 'tubes, to be afterward described. 
 
 The most common displacement of the ovary is dislocation 
 downward into the retro-uterine pouch, to which the name of 
 prolapse of the ovary has been given, as I think, somewhat 
 improperly. I have very little doubt that a large number of 
 women go about with marked dislocation of their ovaries down- 
 ward, without any kind of suffering ; and there is equally no 
 room for doubt that this dislocation is in many cases a source 
 of suffering so great as absolutely to prevent the woman from 
 fulfilling her duties in life, and to render her life a prolonged 
 misery. 
 
 The origin of this peculiar dislocation is very various. I have 
 no doubt that, in some of the cases I have seen, the position of 
 the ovaries in the cul-de-sac was cono^enital ; in others the dislo-
 
 42 DISEASES OF THE OVARIES. 
 
 cation has probably arisen from some accidental strain ; but in 
 by far the largest number of cases it has been due to some acci- 
 dent during the process of involution of the uterus after a con- 
 finement or a miscarriage. In a large number of cases it is 
 associated with retroversion or retroflexion of the uterus, but in 
 others the uterus is nearly normal in direction, and then we can 
 only assume that there has been some relaxation of the perito- 
 neal investments of the ovaries, by which they have been allowed 
 to drop downward and give rise to the trouble. 
 
 There can be no doubt that by far the larger number of these 
 cases arise in a condition which is practically that of subinvolu- 
 tion, and in two anatomical facts we have a complete explana- 
 tion of this result. Turning to Henning's table (p. 4), it will 
 be found that the ovary of the puerperal woman is extremely 
 large — indeed, nearly twice as large as it is at any other time. 
 It is also extremely remarkable that the left ovary increases in 
 the puerperal woman to a much larger extent than does the 
 right, a circumstance which I have no doubt is fully explained 
 by the want of a valve in the left spermatic vein (v. p. b). As 
 the ovaries rise in the abdomen with the pregnant uterus, their 
 ligaments, their tubes, and everything connected with them rise 
 in proportional degree. It is not, therefore, to be wondered at 
 that any incident which interferes with the subinvolution of the 
 uterus after parturition should also affect the ovary. One of 
 the most common results of subinvolution of the uterus is retro- 
 flexion, and therefore it is that we have a large number of these 
 cases of dislocation of the ovary downward associated with this 
 uterine displacement ; and my experience is entirely in accord 
 with that of Professor Goodell, when he says that if we find a 
 dislocated, or, as he calls it, a ''prolapsed" ovary, it is almost sure 
 to be the left. It is therefore practically a subinvolution of the 
 ovary with which we have to deal ; and as in the uterus we have 
 hypersemia of the organ gradually passing into chronic metritis, 
 so we have a similar process occurring in the ovary, and in sev- 
 eral remarkable cases, in which I have been obliged to remove 
 the ovaries on account of extreme suffering, I have found the 
 organs in a condition of chronic inflammation and greatly en- 
 larged, associated with chronic fundal metritis and enlargement 
 of the whole body of the uterus. In these cases intractable 
 menorrhagia has been a leading symptom, and the monthly en- 
 gorgement involved by the process of menstruation leads, of 
 necessity, to an increase of the symptoms and an exaggeration 
 of the pathological condition. 
 
 The history of such a case as this will generally be that of 
 some disturbance after confinement, followed by a prolonged
 
 ERRORS OF DEVELOPMENT OF OVARIES AND OVIDUCTS. 43 
 
 convalescence from childbed, a speedy resumption of menstrua- 
 tion, great difficulty and pain in locomotion, almost always pain 
 on defecation, and pain during sexual intercourse. Besides 
 these local symptoms, there will be very often a number of more 
 or less distinct reflex symptoms, such as headache, pain in the 
 breasts, pain in the back, and pains travelling down the thighs. 
 The loss at the monthly periods will increase until it may amount 
 to absolute flooding. The patient becomes anaemic, dyspeptic, 
 and suffers from symptoms of extreme mental depression, and 
 in course of time she will become an absolute invalid. 
 
 On examination, the uterus will be found to be markedly re- 
 troverted or retroflected, or both, the fundus usually being much 
 enlarged. It may happen, however, that the uterus will retain 
 its normal direction, though it will be rarely found that it is of 
 normal size. Great care must be taken in the examination to 
 ascertain the position of the fundus, because it is quite possible 
 to mistake an enlarged and dislocated ovary for a retroflected 
 fundus, and vice versa. But the fundus may easily be recog- 
 nized with a little care, by finding that the tumor felt is con- 
 tinuous with the cervix. The temptation may be great to replace 
 this by means of the sound, but I would strongly urge, especially 
 on the beginner in gynecology, not to yield to this temptation. 
 The sound is a most dangerous implement, and in the record of 
 more than one of my cases it will be found that an immense 
 increase of suffering has resulted from this practice. The expe- 
 rienced gynecologist should generally be able to replace the de- 
 pressed fundus by the point of his finger, and if he is unable to 
 do this in any particular instance, he may suspect that there is 
 some adhesion which will make it much safer not to use the 
 sound. The leverage of the sound in such a case will exercise 
 an amount of force of which the operator may have no exact 
 knowledge, and which is likely to do more harm than good. If 
 I may here venture to sum up my experience of this instrument, 
 extending over more than twenty years, I would say that it has 
 done an infinite amount of mischief, and that probably we should 
 have lost nothing if it had never been invented, and that the 
 more experience grows in practice the less will this instrument 
 be used. 
 
 If the tumor in the cul-de-sac be found not to be the fundus, 
 then the probability is that it is an ovary; and if it be an ovary, 
 and not adherent, it may easily be pushed upward in the direction 
 of its proper place, and this will generally be found to be toward 
 the left side. If it be an ovary, the peculiar, dull, sickening pain 
 evinced by pressure will at once declare its nature, and if it can- 
 not be easily replaced by the finger, it may be assumed that it is
 
 44 
 
 DISEASES OF THE OVAKIES. 
 
 adherent. The conditions may be fully established by the bi- 
 manual method of examination, and in all probability this will 
 not be done with perfect satisfaction without the assistance of 
 an anaesthetic, and ether is by far the best agent to use. By 
 this method of examination it should, first of all, be ascertained 
 whether or not the ovaries are in their proper place on each side 
 of the uterus. If they cannot be found, it is most probable that 
 the retro-uterine tumor is an ovary, and more particularly if it 
 be adherent I would recommend the greatest caution in dealing 
 with it, for I have more than once seen a smart attack of pelvic 
 peritonitis set up by too rough handling. If the tumor be a 
 fundus, it will probably easily be dealt with ; but if it be an 
 ovary, very great difficulty indeed may be met with in treating 
 the case satisfactorily. If the gland is not adherent, it may be 
 replaced by a pessary, adapted so as to keep it in place, or at 
 least far enough up to be out of harm's way; but, if it be ad- 
 herent, it may be taken as certain that no pessary can be borne. 
 The best pessary for this purpose is one which I introduced 
 many years ago, under the name of the " wedge pessary," and 
 which is here figured. I have frequently had cases brought to 
 
 me in which the sufferings of 
 the patient had been greatly in- 
 creased by well-intended efforts 
 to replace by pessary an adher- 
 ent ovary. 
 
 The general treatment should 
 consist of absolute physiological 
 rest ; that is to say, that during 
 the menstrual period the patient 
 should be confined absolutely to 
 bed, and that there should be a 
 cessation of intercourse. Any 
 kind of treatment which will 
 tend to improve the patient's general health should be em- 
 ployed, and by far the most effectual remedy will be a judicious 
 administration of ergot and the salts of potash. What has 
 proved in my experience to be the best method of giving these 
 drugs is to put the patient on a prolonged course of the bro- 
 mide and chlorate for alternate months, in doses of from five 
 to twenty grains twice daily, and taken continuously; and to this 
 is to be added a pill containing from half a grain to two grains 
 of ergotin, to be taken for a few days before the appearance of 
 menstruation, and during the whole of the period. I am bound 
 to say that no other treatment by drugs has seemed to me to be 
 of the slightest use. Professor Goodell speaks in high praise of 
 
 Fig. 18. — Wedge Pessary.
 
 ERRORS OF DEVELOPMENT OF OVARIES AND OVIDUCTS. 45 
 
 a combination of the amnionic and mercuric chlorides, but I 
 have not found them, of much use. He gives them in the fol- 
 lowing formula : 
 
 J^. Hydrargyri chloridi corrosivi gr. j. 
 
 Ammonii chloridi 3 ij. 
 
 Mist, glycyrrhizse co f- 3 vj. 
 
 M. 
 
 S. — One dessertspoonful after each meal, in a wineglassful of 
 water. 
 
 In addition to this, Professor Goodell recommends treatment 
 by the genu-pectoral position, as introduced by Dr. Campbell ; 
 and in some cases of dislocated ovaries which were not adherent, 
 accompanied by retroflexion and subinvolution of the uterus, I 
 have found this plan to be distinctly effectual. It is, however, 
 very harassing to the patient, for it requires prolong;ed use, and 
 I have not found many women sufficiently persevering to give 
 it an extended trial ; the misfortune in these cases being, like 
 very many others in this line of practice, that almost any treat- 
 ment requires to be continued for so long a time that most suf- 
 ferers are apt to lose patience, and seek other treatment at the 
 hands of some fresh practitioner. I take the following descrip- 
 tion of this postural treatment from Professor Goodell's writings: 
 
 "A very excellent way of keeping up the ovaries — one which, 
 in every case, I adopt, and one which I shall now teach this pa- 
 tient — is the knee-breast posture, devised by Dr. C. F. Campbell, 
 of Georgia. Two or three times a day, or more frequently if 
 needful, this woman will unhook her dress, loosen her under- 
 clothing, and kneel on her bed as she now kneels on this table. 
 Her body is then bent forward until the breast is brought down 
 to the surface of the bed, while her head is turned to one side 
 and supported in the palm of her left hand. Her knees should 
 be about ten inches apart, and the thighs perpendicular to the 
 bed. If she now refrains from straining, and breathe naturally, 
 a reversal of gravity will be established. With the fingers of 
 her free hand she will next open her vulva. Air will rush in, 
 and the abdomen and its contents will at once sag down. This 
 will, of course, draw up the womb and the displaced ovaries out 
 of the pelvic canal. As it is rather awkward for a woman, while 
 in this posture, to free one hand and reach the vulva, Dr. Camp- 
 bell advises that, previously to taking this attitude, she should 
 insert into the vagina a small glass tube, open at both ends, and 
 long enough to project externally. This will leave an air-way, 
 and dispense with the use of the fingers. With such tubes as I
 
 46 DISEASES OF THE OVARIES. 
 
 now show you I furnish each one of my patients ; but you will 
 find a good substitute in the empty barrel of the old-fashioned 
 cylindrical "female syringe," as it is called. After staying in 
 this posture for a few minutes, the woman will remove the tube 
 and slowly turn over on her side, where she will lie as long as 
 she can. Such constant replacements are of great service, for 
 they lessen the throbbing, they give the limp ligaments a chance 
 of shrinking, and they teach the ovaries good habits of staying 
 at home." 
 
 It will, however, often happen that, after all kinds of treat- 
 ment have been employed, and many practitioners consulted 
 without the slightest improvement, or even, it may be, only with 
 the result of increasing the patient's sufferings, that she settles 
 down as a permanent invalid, her life being rendered absolutely 
 miserable, and she being hopelessly invalided by her dislocated 
 ovary. Then there remains as her only hope the operation of 
 ovariotomy. The discussion of this important subject is by no 
 means yet complete, and it is unfortunately one in which much 
 unnecessary and most unfair criticism has been introduced. I 
 shall in another chapter consider more fully the arguments upon 
 this question, but here it will probably be quite enough to quote 
 again the words of Professor Goodell, with the remark that I 
 endorse every word which he says : 
 
 "Once in a while, however, such lasting tissue-changes take 
 place in the ovaries as no medication can reach. The hypertro- 
 phied glands keep heavy, and refuse to float up. Now, must the 
 unfortunate owner of these organs drag out the rest of her men- 
 strual life burdened with the distressing ovaralgia, the crippled 
 locomotion, and with all those aches, and pains, and throbs 
 which I have described to you ? No, indeed ! The source of all 
 this mischief — the ovaries themselves — must be removed. Nor 
 need you fear that such an operation will unsex a woman. In 
 the cases in which it has been performed by myself and by 
 others it in nowise changed the voice, the appearance, or the 
 character of the woman. It merely brought on, more abruptly 
 than nature does, that change of life which every woman longs 
 to reach, and which, while taking away all hope of future off- 
 spring, makes her no less a mother or a wife." 
 
 A great deal of discussion has taken place concerning the 
 merit of having first proposed this operation, and Dr. Marion 
 Sims has thrown the whole weight of his justly great authority 
 in claiming for it an American origin ; and for Dr. Battey he 
 asserts the credit of it, having named it " Battey 's operation." 
 I must, however, in justice to myself, protest against this; and 
 I have to point out that, so far as the records of this operation 
 
 <
 
 ERRORS OF DEVELOPMENT OF OVARIES AND OVIDUCTS. 47 
 
 are known, Professor Hegar, of Fribourg-im-Breisgau, was the 
 first to perform it, and that my first case preceded that of Dr. 
 Battey by several days — all three operations having been per- 
 formed within a fortnight. Further, I have to point out that in 
 the first edition of this book, written in 1872 and published in 
 1874, the essay to which was awarded the Hastings gold medal 
 of the London meeting of the British Medical Association, the 
 following passage occurs : 
 
 " The ovaries are liable to certain displacements, which may 
 give rise to many disagreeable symptoms without any actual 
 disease of the gland. Thus, one or both ovaries may, by a re- 
 laxation of their peritoneal investments, drop into the retro- 
 uterine cul-de-sac, and there be a source of great trouble. This 
 will be especially the case if there be at the same time retro- 
 flexion or retroversion of the uterus ; for I have known such a 
 displacement of an ovary utterly to prevent the application of 
 any apparatus for the replacement of the uterus, and cause so 
 much suffering as almost to make us discuss the question of 
 ovariotomy." 
 
 The details of the history of this operation will be fully dis- 
 cussed in a special chapter. 
 
 In cases where the pelvic viscera are displaced downward so 
 as to form more or less complete protrusion, the ovaries of course 
 share in the dislocation, and they may incidentally inc^rease the 
 amount of distress caused by such a condition ; but as this be- 
 longs more to diseases of the uterus, I shall not dwell further 
 upon it ; and similarly may dismiss the displacement of the 
 ovaries involved in the inversion of the uterus, A more rare 
 displacement of the ovary occurs as the result of an excess of 
 embryonic transition, the gland being carried downward and 
 forward in the direction taken by the testicles of the male in the 
 course of descent. I have not been fortunate enough to have 
 had any experience of this peculiar form of hernia, and what in- 
 formation I can give upon it must be by quotation. It is, how- 
 ever, a matter of such importance that I feel perfectly justified 
 in quoting at length some of the more notable cases which have 
 been placed on record. The instance which has attracted most 
 attention is that narrated by Mr. Percival Pott, of a patient, 
 aged twenty-three., admitted to St. Bartholomew's Hospital, who 
 had two small swellings, one in each groin, which had been for 
 some months so painful as to entirely prevent her following her 
 occupation as a domestic servant. Her menstruation had been 
 perfectly regular, and the tumors were more painful at that 
 time, Mr. Pott found the tumors to be the ovaries, wliich had 
 come down through the inguinal canal. He removed them sue-
 
 48 DISEASES OF THE OVARIES. 
 
 cessmlly, and the patient's health and comfort were speedily 
 and completely re-established ; and menstruation never reap- 
 peared, the last observation on this point having been made 
 several years after the operation. In the record of the case no 
 mention is made as to whether or not Mr. Pott removed the 
 tubes, or any part of them. In the work of L. C. Deneux many 
 very remarkable examples of displacement of the ovary are 
 given, such as its appearance under the crural arch, through 
 the ischiatic notch, as part of the contents of an umbilical her- 
 nia, and of various eccentric ventral and vaginal protrusions. 
 Dr. Busch gives seventy-eight similar observations which he has 
 collected, including fourteen cases in which there was more or 
 less pronounced absence of the uterus, thirteen cases of various 
 kinds of spurious and true hermaphroditism, and four of uni- 
 cornual or bicornual uterus. These observations go to show — 
 and I think all the facts of comparative anatomy indicate it — 
 that the male organism is an advance upon that of the female, 
 and that these cases would have to be regarded more as arrests 
 of development in the direction of the male organs than hyper- 
 erchesis of the female. 
 
 Kiwisch narrates an instance of an ovary forming part of a 
 hernia through the foramen ovale. When the ovary is displaced 
 in this way, it is, of course, quite as apt to undergo cystic de- 
 generation as an ovary in its normal position ; and therefore it 
 is not surprising to find that there is at least one case on record 
 where a cystic ovarian tumor has been removed from outside 
 the inguinal ring. One of the most remarkable cases on record 
 is that published by Mr. W. M. Jones, in the British Medical 
 Journal for 1877, in which the patient seems to have had double 
 congenital hernia of the ovaries, and yet became pregnant. 
 
 "A. E. C , aged twenty-three, came to the out-patient room 
 
 on August 1st, complaining of dragging pains about her abdo- 
 men and a swelling in both labia. She was married, and had 
 one child. Ever since she could remember, when she stood up 
 a small lump descended into each labium, going back again on 
 lying down. She had always suffered from pains in the abdo- 
 men, and at her menstrual periods the lumps themselves were 
 painful. On examination, a small, roundish tumor was found 
 in each labium, feeling like a testicle, and quite easily returnable 
 into the abdomen through the inguinal canal. It was perfectly 
 dull on percussion, and there was no impulse on coughing. Dou- 
 ble ovarian hernia was at once diagnosed, and the diagnosis was 
 confirmed on her coming the following week, during her cata- 
 menial period, with both tumors swollen and tender. An ordi-
 
 ERRORS OF DEVELOPMENT OF OVARIES AND OVIDUCTS. 49 
 
 nary double inguinal truss was given her, which effectually pre- 
 vented the descent of the tumors, and she reported herself last 
 week as being quite well, and entirely free from her abdominal 
 pains. The great interest in this case lies in its analogy to the 
 descent of the testicle in the male, and in the fact that, notwith- 
 standing the malposition of both ovaries, she had actually been 
 impregnated, and given birth to a living child." 
 
 Dr. Worth, of Kiel, narrates an instance of removal of both 
 ovaries on account of double ovarian inguinal hernia. The pa- 
 tient was twenty-three years of age, and had never menstruated, 
 but at each monthly period there was severe abdominal pain. 
 The vagina was occluded, the clitoris was unusually large, and 
 was furnished with a large prepuce ; and under the skin, over 
 the inguinal canal on each side, was a body about the size of a 
 pigeon's egg, resembling a testicle in shape and consistence. 
 These bodies lay symmetrically in the axis of the inguinal canal, 
 the upper end corresponding to the inguinal ring, while the 
 lower and inner end corresponded to the anterior margin of the 
 labium majus. At the upper part of each body was an ill- 
 defined substance of the size, form, and consistence of an epi- 
 didymis. They were both quite irreducible, and looked so very 
 like testicles that the sex of the patient was extremely doubtful. 
 An operation was undertaken for their removal, which was 
 completely successful, and on subsequent examination they 
 proved to be unquestionable ovaries, for they possessed the char- 
 acteristic follicles containing ova. 
 
 Weinlechner {Wiener med. Wochenschrift, 1877) relates a 
 case of inguinal hernia produced by a stumble, and for which a 
 truss had been worn for eighteen weeks, when it came down 
 again and became irreducible. This was followed by vomiting 
 and acute pain ; as taxis failed, and the symptoms of incarcera- 
 tion became more severe, she was admitted into hospital. In the 
 right groin was a tumor the size of a goose-egg, which was 
 marked into two divisions by Poupart's ligament. The symp- 
 toms of incarceration were not quite perfect, and the patient as- 
 serted that the hernial tumor increased at the menstrual periods, 
 that the probability of an ovarian hernia was recognized, and it 
 was confirmed by operation. The swollen and irreducible ovary 
 was removed after ligation of its pedicle, and the patient recov- 
 ered well. 
 
 Dr. J. H. Balleray has written an extremely interesting paper 
 upon a case of this kind, to which he appends some valuable ref- 
 erences, and I therefore here insert the whole of his observations. 
 
 " The hernial tumor was large, and seemed to be divided ifito 
 4
 
 50 DISEASES OF THE OVARIES. 
 
 two portions by a sulcus ; the skin covering it was somewhat 
 inflamed and tender to the touch. There was something very 
 pecuhar about the feel of the tumor, especially at its lower por- 
 tion. The sensation communicated to the finger was such as to 
 satisfy me at once that I had to deal with something out of the 
 usual order of things, but as to what the real character of the 
 hernial tumor was I had no definite idea. I therefore requested 
 my friend, Dr. E. J. Marsh, to see the case with me. He did so, 
 and seemed to be as much puzzled as I was. He suggested, 
 however, the possibility of the ovary having found its way into 
 the hernial sac. Taxis having failed to effect reduction of the 
 hernia, and the patient's condition being critical, both Dr. Marsh 
 and myself were convinced that an operation was imperative, 
 and that it should be performed without delay. 
 
 '' Having informed the patient's husband of the result of our 
 deliberations, he requested that we should proceed with the opera- 
 tion at once, if in our judgment it was necessary. Accordingly, 
 with the kind assistance of Drs. Marsh and Rogers, I proceeded 
 to operate. Having cut down to the sac, this was cautiously 
 opened, and about four ounces of brownish yellow fluid escaped, 
 when, to my surprise, there was neither intestine nor omentum 
 to be seen, but the left ovary was found lying near the lower 
 portion of the sac, and tightly strangulated by a firm, fibrous 
 band, which extended from one wall of the sac to the other, and 
 constricted the ovary at about its upper third. This band was 
 divided, and the ovary liberated. It was found to be very deeply 
 congested, but as its vitality did not seem to be destroyed, I de- 
 cided, after consultation with my confreres, to return it into the 
 abdominal cavity. The wound was then closed in the usual 
 way, a pad and bandage applied, and the patient put to bed. 
 
 "She rallied well from the operation, and at tlie end of the 
 third week she was convalescent. The enterocele returned, how- 
 ever, after she began to walk about, and she has, therefore, 
 been obliged to wear a well-adjusted truss, which enables her to 
 attend to her household duties with a greater degree of comfort 
 than she had enjoyed for years before. 
 
 " In January, 1864, Mr. Holmes Coote reported, at a meeting 
 of the Royal Medical and Chirurgical Society, a ' case in which 
 the left ovary was found in the sac of an oblique inguinal her- 
 nia.' A young woman was brought into St. Bartholomew's Hos- 
 pital with a swelling in the left groin, and suffering from the 
 symptoms of strangulated hernia. In the course of a few hours 
 the usual operation was performed, when the ovary and Fallo- 
 pian tube were found in the sac. The left ovary was removed, 
 some thickened omentum cut away, and the patient was put to
 
 EUROKS OF DEVELOPMENT OF OVARIES AND OVIDUCTS. 51 
 
 bed ; but the sickness and. constipation continued, and she died 
 four days after the operation. The cause of the sickness, etc., 
 was displacement of the stomach and transverse arch of the 
 colon. In the discussion which followed the report of this case, 
 Mr. Csesar Hawkins stated that he had met with two cases in 
 which the ovary was found in the hernial sac. In one of these 
 the patient was an elderly woman, and died of peritonitis. In 
 these cases he thought the better practice was to leave the ovary 
 in the sac, as its removal was attended with danger. 
 
 " Dr. Frank H. Hamilton, of New York, assisted by Dr. Terry, 
 collected reports of twelve cases of ovarian hernia occurring in 
 the inguinal region, most of which were operated upon before a 
 diagnosis was made. These cases were published in the ' Belle- 
 vue Hospital Reports,' 1870, p. 159. Dr. Hamilton himself has 
 seen one example of congenital ovarian inguinal hernia. The 
 late Dr. J. C. Nott met with a case of ovarian hernia at the in- 
 guinal ring, in a lady sixty years of age, which, being strangu- 
 lated, he was able to reduce by taxis. A very interesting case 
 is also reported by Dr. Alfred Meadows, in the ' Transactions of 
 the Obstetrical Society of London,' vol. iii., p. 438. 
 
 " In cases of strangulated ovary, the question as to whether the 
 ovary should, after division of the stricture, be returned into the ab- 
 dominal cavity or left in the hernial sac, ought, in my judgment, 
 to be determined by the condition of the organ itself. The rule 
 by which the surgeon is governed in the managemxcnt of strangu- 
 lated intestine or omentum is, I think, applicable to these cases. 
 
 " According to Hamilton {' Principles and Practice of Sur- 
 gery'), Neboux, Mulert, and Krieger returned the ovary into the 
 abdomen, and their patients got well. Deneux, on the other 
 hand, cut away the ovary, and the patient was well in twenty- 
 nine days. Berard found both the ovary and Fallopian tube in 
 a sac, which he supposed to be a serous cyst. Having opened it, 
 suppuration ensued and the patient died. 
 
 " The method of dealing with the ovary adopted in my own 
 case was, I think, justified by the result, and in similar cases I 
 would, recommend similar treatment. But in cases in which, 
 from long continuance of the strangulation, or excessive tight- 
 ness of the stricture, the tissues of the ovary either are or are 
 likely to become gangrenous, removal of the organ is, in my 
 opinion, the proper course to pursue." 
 
 One of the most remarkable cases of ovarian hernia is the 
 following, narrated by Dr. Leopold, in which the left cornu of 
 the uterus was included in the protrusion, and removed with its 
 corresponding ovary.
 
 52 DISEASES OF THE OVARIES. 
 
 A woman, aged twenty-eight, the issue of parents who had 
 had seventeen children well formed, experienced for the first 
 time, at the age of fourteen, the menstrual molimen. This mo- 
 limen reappeared regularly every twenty-six or twenty-eight 
 days, but was not followed by any loss. It was accompanied 
 with pains which were localized in the left inguinal region, 
 lasting several days. In process of time the patient remarked 
 that, from the first day of the molimen, a body of the size of a 
 plum rose in the left groin, and that this body became larger 
 every day, and only resumed its former volume several days 
 after the period. At length there resulted from it an exces- 
 sive irritability and a grave alteration of the nervous system. 
 Married at twenty, she, with the advice of her husband, had 
 recourse to a gynecologist, who, finding the vagina absent, en- 
 deavored, by incision and dilatation with tents, to form a pas- 
 sage to the uterus, in order to remedy a supposed retention of 
 the menstrual blood. The treatment was fortunately interrupted, 
 but there occurred afterward, and especially in 1877, vicarious 
 hemorrhages from the nose and lungs. 
 
 In March, 1.S78, she placed herself under the care of Dr. Leo- 
 pold, who, after having treated her for more than twelve months, 
 published this remarkable observation : 
 
 " The breasts, pelvis and vulva were well conformed, but the 
 vagina terminated in a cul-de-sac 8 ctm. in depth. In this 
 place there was no indication of a vaginal portion, and above 
 there was no trace of either uterus or ovaries. 
 
 In the left groin, on a level with the external inguinal ring, 
 was perceived an uneven tumor of about the size of half a hen's 
 egg, painful, hardly movable, almost on a parallel in its great 
 axis with the inguinal fold, and resembling an ovary abnormally 
 situated. On the right side the inguinal region was normal ; but 
 on deep pressure a small body was felt, resembling that met 
 with on the left side, but more movable, less painful, and much 
 smaller. 
 
 The pain caused by the tumor on the left side became at 
 length so acute that an operation was performed on February 
 15, 1879. The tumor was removed. It was not, as had been di- 
 agnosed, an ovary, but a rudimentary utqrine cornu. At the 
 same time the neighboring tube and ovary were removed. After 
 the abdominal cavity had been thoroughly cleansed, and the 
 ligatures cut short, the T-shaped wound was closed by five deep 
 sutures of silver wire, including the peritoneum, 'and by several 
 superficial sutures of silk thread, and at the point of union of the 
 two incisions a small drainage-tube was introduced to a depth of 
 about one centimetre. 
 
 i
 
 ERRORS OF DEVELOPMENT OF OVARIES AND OVIDUCTS. 53 
 
 No fever followed, and fourteen days afterward the wound 
 had perfectly healed. The time of the menstrual epoch passed 
 without the least trouble, only that there were some contractions 
 in the muscles of the left leg. 
 
 The amputated cornu uteri, of the size of the thumb, pre- 
 sented the histological structure of the uterus ; that is, smooth 
 fibres, conjunctive tissue, vessels, and glands. The ovary pre- 
 sented all the characteristics of normal structure, with yellow 
 bodies and vesicles at various stages of development. The tube 
 has a pavilion beautifully fringed, but there was no canal con- 
 tinuous with the infundibulum.'*' 
 
 Dr. Alfred Meadows has also placed upon record, in the 
 ''Transactions of the Obstetrical Society" (vol. ii.), a case in 
 which he removed a hernial ovary. 
 
 I have also met with a very singular case of ovarian displace- 
 ment, where the condition was evidently congenital, and was 
 discovered only when an operation had to be performed for the 
 removal of the misplaced ovary on account of cystic degenera- 
 tion. The tumor was of very large size, and for its removal the 
 usual median incision was made between the umbilicus and the 
 pubes. No difficulty was encountered until I attempted to drag 
 the upper part down through the incision, when I found a broad 
 band of union extending upward from the umbilicus. The peri- 
 toneum passed from the abdominal walls on to the tumor, just 
 as it does on to the rectum, and the union was evidently not 
 merely inflammatory adhesion. On dividing the peritoneum, I 
 found that the common tendon formed part of the cyst- wall, and 
 that the fibres of the rectus abdominis muscle were inserted into 
 the cyst. The round ligament of the liver ran through the cyst- 
 wall to the umbilicus, and, on being cut through, the umbilical 
 vein contained in it bled profusely, and had to be tied. Very 
 careful dissection had to be made to remove the cyst, and when 
 it was completed it was found that a large triangular gap was 
 left in the abdominal wall, covered only by skin, and having its 
 base at the umbilicus and its apex at the xiphoid cartilage. 
 This gap was closed by subcutaneous stitches of silver wire, and 
 the patient made a complete recovery, and has since been safely 
 confined of a living child. Careful examination of the tumor 
 satisfied me that the only explanation which could possibly be 
 offered of these unusual conditions was that the ovary had be- 
 come attached to the cleft in the visceral arches during early 
 embryonic life, and had subsequently been affected by cystic 
 degeneration.
 
 54 DISEASES OF THE OVARIES. 
 
 Klob has described a twisting of the ovary on its axis, which 
 is probably congenital, and has not yet been found to be of any 
 pathological importance in an otherwise healthy ovary. In the 
 cystic ovary a similar twisting has been observed to a more 
 complete extent, and with disastrous results, as will afterward 
 be described. The ovary is said sometimes to be completely de- 
 tached from its normal position and relations, and forms new 
 attachments elsewhere. This occurs with the healthy ovary, 
 and, as Mr. Spencer Wells has shown, also probably after it has 
 undergone degeneration. How and when it occurs have not yet 
 been satisfactorily explained, but in all probability the curious 
 axial rotation to which ovarian tumors are subject, as described 
 in a subsequent chapter, has something to do with it. 
 
 In some rare instances we find the peritoneal layers so defi- 
 cient that the ordinary mesenteries and ligamentous folds are 
 completely absent. I have described several cases of congenital 
 defects of the peritoneum {Dublin Quarterly Journal of Medical 
 Science for February, 18G9), but the most interesting I have met 
 with is one I published in the Obstetrical Journal for October, 
 187G. There the peritoneal sac was wholly absent, the intestines 
 being connected together by an abundance of extremely loose 
 cellular tissue. In the pelvis it was absolutely impossible, on 
 post-mortem examination, to identify any organ but the uterus, 
 from the entire absence of any of the usual peritoneal limita- 
 tions. Thus, the bladder was torn open in removing the uterus, 
 under the impression that it was some of the loose areolar tissue, 
 and its nature was recognized only by the escape of urine. Two 
 masses close to the uterus, one on either side, when cleared of 
 the abundant connective tissue and laid open, proved to be the 
 ovaries, and in the left there was the clot of a recent Graafian 
 follicle, the ovum of which, if it ever were extruded, must have 
 been arrested in the surrounding tissue. Over the right ovary 
 the Fallopian tube seemed to course in a normal direction, but 
 it became lost in a mass of connective tissue, and I could find no 
 appearance of the fimbriated expansion. On the left side there 
 was an appearance of a rudimentary tube in a fold of tissue. 
 
 The menstrual history of the patient, as ascertained by my 
 friend Dr. Hickinbotham, in consultation with whom I saw the 
 patient during her life, was in no way abnormal, and she was 
 twenty-five years of age. The cause of her death was the ob- 
 struction of scybalous masses in a bunch of coils of intestine, 
 along which they could not pass, apparently because the intes- 
 tines were unable to move about. 
 
 Another class of remarkable errors of development of the 
 ovary consists of those to which I have given the name of hy- 
 
 i
 
 ERRORS OF DEVELOPMEI^^T OF OVARIES AISTD OVIDUCTS. 55 
 
 pererchesis. So far as I know, they are limited to the development 
 of fetal structures in the ovum before it has left the follicle, this 
 taking place probably during the fetal existence of the ovary, 
 and constituting, in after-life, the variety of ovarian tumor 
 known as " dermoid," under which head this remarkable change 
 will be found fully discussed. They are also seen in the peculiar 
 growths resulting, as I believe, from the extended life of ova 
 which have been dropped out of the follicle into the peritoneal 
 cavity, and there have continued their existence, becoming de- 
 veloped into huge cysts, instead of perishing, as they usually 
 do. In the chapter upon ovarian tumors several instances of 
 these will be described. 
 
 The errors of development of the Fallopian tube partake very 
 much of the same character as those affecting the ovary. When 
 the gland is insufficiently developed, its tube will be found cor- 
 respondingly defective. I have, however, already narrated a 
 case in which, coincident with defective development of the 
 peritoneum, the growth of the tubes had been apparently ar- 
 rested, while the ovaries had not suffered in this way. Some- 
 times, also, we find the tubes are displaced by congenital defect, 
 being placed either too low, or being too short, or having their 
 infundibula too small to enable them to acquire their periodic 
 relations to the ovaries properly, and in these cases there is of 
 necessity a resulting sterility. Conversely, we sometimes find 
 that a badly developed ovary, or, it may be, an ovary which has 
 suffered from infiammation, is displaced downward and out- 
 ward, beyond the reach of the normal tube ; and here again 
 sterility is produced. 
 
 In some instances of arrested development of the tubes they 
 are found to be occluded at both ends, and distended by the 
 fluid into cysts. I have found, in several instances, that this oc- 
 clusion at the outer extremity of the tul^e was formed by an ad- 
 hesion of a permanent kind to the inf undibulum of the ovary, 
 perhaps of a congenital origin, but more probably the result of 
 inflammation. In these cases extreme menstrual pain has 
 resulted from periodic distention of the tubes, the patients 
 have been sterile, and, when married, have been wholly un- 
 able to perform their marital functions. They have wandered 
 about from one practitioner to another, and from hospital to 
 hospital, vainly seeking relief, and the only means of giving 
 it to them is to remove the ovaries and the tubes. Two or 
 three characteristic examples of this condition I propose here to 
 describe. 
 
 Such inflammatory affections as spread into the uterus are 
 apt to pass along the tubes and produce ovarian or peritoneal
 
 56 DISEASES OF THE OVARIES. 
 
 mischief. In this way the inflammation of the tubes is of im- 
 mense importance, and it may be suspected after the appearance 
 of indications of the more serious extension of the disease. It 
 may also have an important result, in addition to the extension 
 of the inflammation, in the form of destructive desquamation of 
 the ciliated epithelium which lines the tubes. The function of 
 this ciliated epithelium, as well as that of the peristaltic move- 
 ments of the tubes, is evidently chiefly for the passage down- 
 ward of the ovum ; but it also seems to me likely that it is to 
 hinder the contact of the spermatozoa with the ovum until the 
 latter has reached the cavity suited for its maturation. The 
 statement that impregnation takes place before the ovum has 
 reached the true uterus seems to me an assumption based on in- 
 sufficient evidence — indeed, on no evidence at all. A priori, we 
 may safely say that, if it is the rule. Fallopian pregnancies and 
 the disasters which follow them ought to be much more common 
 than they are, and I believe it to be more than likely that the 
 real cause of this accident is the coincidence of a set of circum- 
 stances, the most important of which is the destruction or in- 
 sufficiency of the ciliary movement. Inflammatory desquama- 
 tion may then be a cause, and probably is not an infrequent 
 one, of tubal pregnancy. Destruction of the tubal epithelium 
 may also, and undoubtedly often does, cause atrophy or occlusion 
 of the tubes, and occlusion of the apertures of the tubes may be 
 the cause of another disease of the tubes, of which I have seen a 
 considerable number of cases — dropsical distention. The fact 
 which is mentioned by many authors, that both tubes are usu- 
 ally affected, is suggestive that tubal dropsy is generally the 
 result of inflammatory action. The distended tubes seldom reach 
 a large size, and the majority of the cases, where they are de- 
 scribed as having reached such a size as to rival and demand 
 the treatment of ovarian tumors, are open to the suspicion of 
 inaccurate description. There is, however, one case given by 
 Dr. Peaslee in his book on ovarian tumors, about which there 
 can be no doubt. It contained eighteen pounds of fluid, and 
 would have been removed if the patient had recovered from the 
 tapping. 
 
 In some six or seven cases where I have found the Fallopian 
 tubes distended with fluid, and where I could not remove them, 
 I have drained them by the process I have described elsewhere 
 as applicable to cysts of the liver and kidney and to pelvic ab- 
 scesses. I first of all expose the cyst, then empty it by the aspi- 
 rator, and then enlarge the opening into and stitch its edges 
 to the edges of the parietal wound by a continuous suture, so 
 as completely to close the peritoneal cavity. The cavity of the
 
 ERRORS OF DEVELOPMENT OF OVARIES AND OVIDUCTS. 57 
 
 cyst is carefully drained in front, or by a tube passing both up- 
 ward and downward, as well as into the vagina. I have in this 
 way cured cases of hydro-, pyo-, and hsematosalpinx, but the 
 results and the rate of progress are not nearly so satisfactory as 
 when the uterine appendages are completely removed. 
 
 This occlusion of the Fallopian tubes, which is certainly of 
 very frequent occurrence, is facilitated by the relations of the 
 infundibulum to the ovary, this being far more intimate than is 
 generally imagined. Fig. 1 (p. 4) gives a perfectly exact repre- 
 sentation of the organs, but in order to display them their rela- 
 tions have been destroyed, for the fimbriae are always in close 
 relation to the ovary, and the tubes, as I have said, curl over and 
 around the ovary, so that the infundibulum is in contact with the 
 lower and posterior surface of the ovary, the axis of which is 
 often nearly vertical generally, but not always. Adhesion, as I 
 have said, occurs at the menstrual periods independently of ovu- 
 lation, and I think it more than probable that not more than one 
 in ten of the ova shed by the glands really enter the tubes. The 
 rest drop into the peritoneum and die there. 
 
 The largest collection of fluid which I have seen in an oc- 
 cluded Fallopian tube occurred in the following case, the more 
 remarkable in that the disease was unilateral. 
 
 E. E. T , aged twenty-eight, was placed under my care by 
 
 Mr. Watkin Williams, of this town. She had been married, but 
 had been obliged to divorce her husband for misconduct. It is 
 more than probable that gonorrhoea had been communicated to 
 her about five years before I saw her. From that date she had 
 suffered from intense pain during the menstrual period, and had 
 become very much emaciated. She had been under a great many 
 doctors without obtaining relief. I discovered a small cystic tu- 
 mor behind and to the right of the uterus, freely movable, but 
 very painful when moved. I advised its removal, and this I un- 
 dertook on May 23, 1879. I found it to consist of the right Fallo- 
 pian tube, distended by about a pint of clear serum. The infun- 
 dibulum was glued on to the right ovary, and the' uterine part 
 of the tube was distended like a tortuous sausage, the greater 
 part of the cyst being made from the outer half of the tube. 
 I removed the tube and left the ovary. She made an easy 
 recovery, is now in robust and perfect health, and has married 
 again. 
 
 Dr. Saundby examined the fluid removed, and gave me the fol- 
 lowing report upon it : specific gravity, 1014 ; reaction alkaline, 
 pale greenish color, clear, with scanty grayish deposit ; contains 
 about three-fifths of its volume of an albuminous body, having
 
 58 DISEASES OF THE OVARIES. 
 
 all the characters of serum-albumen. After removing the albu- 
 men, the filtrate precipitates with mercuric nitrate (urea ?) and 
 with argentic nitrate (chloride of sodium ?). The microscopical 
 examination showed only a few indifferent cells. 
 
 E. C , aged thirty -two, was married at seventeen years of 
 
 age, and had her first child when she was eighteen, and her 
 second in the following year. She was quite well until 1876, 
 when she had a smart attack of inflammation of the pelvis, and 
 ever after that she had extreme pain at her periods, when she 
 had to remain in bed for several days ; and she described her 
 sufferings as amounting to agony, and resembling labor-pains 
 more than anything that she knew of. She was seldom free 
 from pain in the back, and for the last three years she has been 
 utterly unable to endure married life. I found the uterus 
 slightly retroverted, and on each side of it there was a distinct 
 mass in the position of the ovary, large, fixed, and extremely 
 tender. She had been under a great variety of treatments, with- 
 out the slightest benefit. On October 5, 1880, I made an explora- 
 tory incision, and found both ovaries adherent in the cul-de-sac, 
 the infundibula of both tubes occluded, and the tubes themselves 
 distended into cysts. The whole of the organs were matted to- 
 gether, and the operation for their complete removal was ex- 
 tremely difficult. The amount of fluid in each tube was about 
 two ounces. She made an uninterrupted recovery from the 
 operation until the monthly period after, at which time she had 
 a small hsematocele on the right side, coincident with a slight 
 menstrual appearance. From this, however, she speedily re- 
 covered, and on February 17th last I found the uterus per- 
 fectly free and normal in direction. I last saw her on March 
 2Gth, and found her in perfect health, absolutely free from pain, 
 and she told me that she had seen no appearance of menstrua- 
 tion since November, and that marital functions had been re- 
 sumed without the slightest pain. 
 
 H. S , aged thirty-seven, had been married seventeen 
 
 years, and had only one child, fifteen years ago. She did not 
 recover well from that confinement, and ever since had men- 
 struated too often and too profusely, being rarely a fortnight 
 clear. I found the fundus large and tender, somewhat ante- 
 verted, and what I regarded as the ovaries formed two large 
 masses low down, and somewhat behind the uterus. For a long 
 time past sexual intercourse had been quite impossible on ac- 
 count of the suffering it caused her. Dr. C. H. Phillips, of Han- 
 ley, who placed her under my care, had exercised a large amount
 
 ERRORS OF DEVELOPMENT OF OVARIES AND OVIDUCTS. 59 
 
 of ingenuity in her treatment, without any benefit, and from 
 February till August, 1880, we conducted further treatment 
 equally in vain. On August 3d I opened the abdomen, and 
 found the ovaries large, completely adherent in the cul-de-sac, 
 covered with lymph, and having the infundibula of the tubes 
 occluded. The tubes were distended into large cysts, each con- 
 taining from four to five ounces of clear serum. The organs 
 had to be very carefully detached, as the adhesions were ex- 
 tremely firm, and the hemorrhage during the operation was 
 tolerably profuse. Her recovery from the operation was rapid 
 and easy, and the only distresses she encountered were the cli- 
 macteric flushings. In May last Dr. Phillips sent me a most 
 satisfactory account of her condition. 
 
 A. S , aged thirty-eight, had been twice married, and had 
 
 had five children by her first husband, the youngest being twelve 
 years of age. She has had no children by the second husband, 
 to whom she has been married six years. After her second 
 
 Fig. 19.— Bilateral hydrosalpinx (after Hooper, from Arthur Farre, Encyc. Anat. and Physiol.): a, 
 uterus ; 6, vagina ; c, os uteri ; d and /, Fallopian tubes ; e, ovary. 
 
 marriage she seems to have had an attack of pelvic inflamma- 
 tion, and ever since she has had intense pain at her periods. 
 She refer] e 1 this pain distinctly to the region of the ovaries. 
 For somewhere about three years she had been wholly unable to 
 submit to intercourse, and her domestic life was thereby ren- 
 dered extremely uncomfortable. I found the uterus to be normal 
 in position, and on each side of it I found a mass situated quite 
 low down, and having characteristics exactly like those in the 
 two cases given above, so that I had no hesitation in making up
 
 60 
 
 DISEASES OF THE OVARIES. 
 
 Fig. 20. — Occluded and adherent Fallopian tubes (Arthur Farre, after Hooper) ; 
 tubes ; d, d, ovaries ; e, e, bands of adhesion. 
 
 a, uterus ; b. Fallopian 
 
 Fig. 21.— Kigrht (A) and left (B) Fallopian Tubes and Ovaries, removed by abdominal section from a 
 patient apred thirty, who had siiffpred early in her married life from gonorrhoea. The large bulbous masses 
 are the Fallopian tubes occluded and distended with serum (hydrosalpinx), the sbriveljed ovaries being 
 shown in the convexity of the tubes. (From a photograph slightly reduced. Preparation now in Museum 
 of Royal College of Surgeons,)
 
 ERRORS OF DEVELOPMENT OF OVARIES AND OVIDUCTS. 61 
 
 my mind that she had occlusion and distention of the tubes. 
 Dr. Cameron, of Bilston, who had placed her under my care, sent 
 her to me with a statement to the effect that he was perfectly 
 sure that nothing but an operation would relieve her. This I 
 performed upon May :21st, and found matters exactly as described 
 in the last case. Her recovery was rapid, and the relief imme- 
 diate and complete. 
 
 In some cases we find that the contents of these closed tubes 
 consist of pus or menstrual fluid, both of which I can instance 
 from my experience in the following cases. 
 
 Mrs. L , aged thirty-four, was sent to me by Dr. McLinc- 
 
 tock, of Church Stretton, in September, 1878. She had been 
 married four and a half years, and had one child. Since her 
 confinement she had never been well, and had suffered from 
 symptoms which clearly were those of subinvolution and retro- 
 flexion. She had profuse menstruation, and on consulting a phy- 
 sician, in July, 1872, she was told she had a tumor behind the 
 womb, and that the womb must be dilated and the tumor re- 
 moved. For this purpose a sponge-tent was introduced, and 
 inadvertently left in, according to her reiterated statement, for 
 nine days. She had suffered from an attack of "acute inflamma- 
 tion of the bowels, and was in her bed for seven weeks." This 
 incident occurred, I am pleased to say, neither in Church Stret- 
 ton nor in Birmingham. When she came to me on September 24, 
 1878, she was in a w^retched state of exhaustion and emaciation. 
 I found a mass on the right side of the uterus, which fluctuated 
 indistinctly. The uterus was retroflexed and fixed completely by 
 perimetric effusion. I tapped the mass, and removed about four 
 ounces of pus from what I now know was an abscess of the right 
 ovary. She was much relieved, and returned to Church Stretton 
 under Dr. McLinctock's care, and slowly gained some strength. 
 She did not make anything like a recovery, however, and her 
 medical attendant sent her back several times to me, and to- 
 gether we carried on a variety of treatment, without much bene- 
 fit. The uterus remained fixed, and all efforts to replace it were 
 so painful that she could not endure them. She could not bear 
 intercourse, and she never was a day without pain, and her life 
 was fitly described as a burden to herself and her relatives. 
 
 Dr. McLinctock sent her down to me again at the end of last 
 February, and in his letter he told me he was sure something 
 more must be done if our patient's life was to be saved. I found 
 that the mass on the right of the uterus was just as I had left it, 
 that the uterus was still fixed and retroflexed, that there was 
 now a more clearly defined mass to the left of the uterus, and
 
 62 DISEASES OF THE OVAKIES. 
 
 that the whole roof of the pelvis was exquisitely tender to the 
 touch. Her temperature went up at night, and she had night- 
 sweats; and although I could feel no fluctuation, I had no doubt 
 there was pus somewhere. I therefore advised and performed 
 an exploratory incision on March Gth. I found the pelvis roofed 
 over by adherent coils of intestine, which I lifted with much 
 trpuble. Below this the whole of the organs were matted to- 
 gether, and their identification was a matter of the greatest dif- 
 ficulty. Finally, I succeeded in recognizing the right Fallopian 
 tube, distended into a cyst with greatly thickened walls, and 
 full of pus. Below it, and intimately adherent to it, lay the 
 ovary, as large as an orange, and containing some old cheesy 
 matter, the remains, probably, of the abscess which I tapped 
 two and a half years before. The uterus was bound down in the 
 cul-de-sac by old adhesions, and from these I relieved it. I 
 found the left ovary adherent below the fundus, and from it the 
 left Fallopian tube ran a circuitous course, like a sausage in ap- 
 pearance, and adherent to the brim of the pelvis, the uterus, and 
 a piece of small intestine. It contained about two ounces of pus. 
 I removed both ovaries and both tubes, cutting the latter off 
 close to their uterine attachments. The hemorrhage during the 
 operation was very troublesome, but was controlled by sponge- 
 pressure. Mr. J. Raffles Harmar assisted me, and Mr. Wright 
 Wilson gave ether. 
 
 The patient has recovered without a bad symptom, and is 
 perfectly free from pain for the first time since the incident of 
 the sponge-tent. The uterus is now perfectly free, and any 
 movement of it gives her no pain. My only regret about this 
 case is that I did not operate two years before. 
 
 J. H , aged thirty-one, came under my care in April last, 
 
 after having been under the treatment of many well-known 
 practitioners. There was no history of any acute illness, but for 
 many months she had been ailing, unable to walk, and con- 
 stantly in pain, and her sufferings during the menstrual week 
 were very great. She was desirous of getting married, but, as 
 she was quite unable to get about, this was out of the question. 
 She had been told by all her doctors that she suffered from a 
 displaced womb. On either side of the uterus was a large, fixed 
 mass, the slightest pressure on which produced pain of a sicken- 
 ing kind. No fluctuation could be determined. She used iodine 
 blisters and took bromide of potash for two months, without any 
 benefit. At the end of June I proposed an abdominal section, 
 but only with the result that she consulted another practitioner, 
 greatly my senior, and under whose care she had previously
 
 ERRORS OF DEVELOPMENT OF OVARIES AND OVIDUCTS. G3 
 
 been, who told her that she ought never to submit to any such 
 proposal. 
 
 She came back to me, however, in August, and I took advan- 
 tage of the presence of Dr. Battey in my house as a guest to get his 
 advice. He agreed with me that it was a case urgently demand- 
 ing interference. This induced her friends to take her to an emi- 
 nent specialist at a distance, who characterized my proposal as 
 absurd ; but yet the poor girl got no better, and she returned to 
 me on October iSth, determined to have the operation performed. 
 
 One matter of importance was the question of her affianced 
 husband's knowledge and consent, and this I desired should be 
 secured. For that purpose I had an interview with him, and 
 fully explained the case and my proposed treatment. He raised 
 not the slightest objection, and expressed himself as desirous 
 only of obtaining relief for his fiancee. The operation was per- 
 formed on October 21st, and I found the pelvic organs completely 
 matted together. After I had separated them — a matter of great 
 difficulty, taking a long time in its performance — I found the left 
 Fallopian tube distended and as big as an orange. Unfortu- 
 nately it burst, and the curdy pus with which it was filled was 
 scattered into the peritoneum ; and a similar misfortune occurred 
 in the removal of the right tube, which was also distended with 
 pus. I need not say that I took every care to cleanse the pelvis 
 well out, and I used a drainage-tube. The removal of the tubes 
 and ovaries in this case constituted the most protracted and 
 difficult operation I have ever performed. The patient recovered 
 speedily and completely, has not menstruated, and is completely 
 free from pain. 
 
 At the meeting of the Societe Anatomique, held on January 
 16, 1880, a case of pyosalpinx was narrated from Dr. Bernutz's 
 service at La Charite. The patient was aged twenty-nine, and 
 was admitted with very severe symptoms, pointing to pelvic in- 
 flammation, and subsequently, peritonitis. She died four days 
 after admission, and, on a post-mortem examination, suppura- 
 tive peritonitis was found to have spread up from the pelvis, 
 having arisen from the rupture of a tubal abscess. The follow- 
 ing is a description of the parts : 
 
 '' The tubes extended one on either side, and were the seat of 
 the principal alterations. The internal half of each tube was 
 healthy, and its direction normal, but the outer half presented 
 three or four dilatations, varying in size, the largest being situ- 
 ated at the oute.r extremity, being formed by the occlusion of the 
 pavilion, so that there was no opening into the tube, which was 
 distended with pus. These dilatations communicated one with
 
 64 DISEASES OF THE OVARIES. 
 
 another, and the internal mucous surface was smooth and 
 softened, but otherwise normal. There was no communication 
 between the uterus and the tubes. The ovaries did not occupy 
 their usual situation, being both displaced downward and em- 
 braced by the concavity of the tube, making w^ith this a largish 
 mass. On the left side there w^as a peculiar arrangement ; a cyst 
 occupied the pavilion of the tube, of the size of a hen's egg, which 
 seemed to be directly continuous with the cavity of the ovary, 
 and the two cysts were entirely empty. The internal surface of 
 the tube was smooth, while that of the ovary was very rough 
 and much reddened, the difference being distinctly marked by 
 a line of division of the two structures. The ovary was not 
 greatly enlarged, and upon its posterior surface, toward the mid- 
 dle, was found a small rupture through which the contents had 
 been extravasated into the peritoneum.'' 
 
 M. Bernutz remarks that in all probability the suppuration of 
 the tubes and left ovary was of ancient date, and that the fatal 
 peritonitis was undoubtedly due to the perforation of the abscess 
 into the peritoneum. He does not give any explanation or his- 
 tory of the pyosalpinx. The case, however, is to. me an extremely 
 interesting one, for it illustrates exactly the same conditions as 
 those seen in the case narrated above, and I think there is little 
 reason to doubt that, if the patient had been seen earlier in her 
 history, the symptoms would have been found sufficiently severe 
 to warrant an abdominal section; and, if that had been done be- 
 fore the rupture, not only would the patient's life have been saved, 
 but her disease w^ould have been cured. Even after the rupture 
 of the cyst and the onset of peritonitis, had the case been under 
 my care, I would have opened the abdomen without the slightest 
 hesitation, have cleaned out the cavity, and removed the cause 
 of the disease. I have had numerous cases in my recent prac- 
 tice where such a proceeding — which would have been regarded 
 as madness three years ago — has had the most brilliantly suc- 
 cessful results. 
 
 As another instance of pyo-salpinx, I may give the following: 
 
 M. F . aged twenty-six, had been, ever since the age of 
 
 seventeen, living an immoral life. About three years ago she 
 suffered from gonorrhoea, which was followed by severe pelvic 
 inflammation, and ever since that time she had suffered from 
 severe menstrual pain. About six weeks previous to my seeing 
 her she had been exposed for a whole night to extfeme cold, and 
 after that suffered from great pelvic pain. She was placed under 
 my care in March last, by Mr. John Green, of this -town. I found 
 her suffering from all the symptoms of pelvic suppuration, and
 
 EKROKS OF DEVELOPMENT OF OVAKIES AND OVIDUCTS. (j~) 
 
 there was a fluctuating pelvic tumor on the left side of the ute- 
 rus. This I diagnosed to be the left Fallopian tube distended 
 with pus. I opened the abdomen on March 28th, and found my 
 diagnosis correct. It was, however, quite impossible to remove 
 the tube, and I therefore had to content myself with emptying 
 it, dragging it up to the wound, securing the two openings to- 
 gether by a continuous suture, and fastening in a drainage-tube, 
 this was kept in for some weeks, and she made a satisfactory 
 recovery. Her menstrual suffering, however, is quite unrelieved, 
 and therefore the cure is only partial. It could only have been 
 made complete by the removal of both tubes and ovaries, but 
 this was made quite impossible by the dense adhesions formed 
 by the previous inflammation. In such a case, of course, there 
 is not the slightest hope of her ever becoming a mother, though, 
 as she has left her irregular life and has been married for about 
 a year, this would be desirable. As it is, she will certainly re- 
 main a sufferer until she reaches the climacteric. 
 
 A few days ago I operated on a patient sent to me by Dr. 
 Standish. of Cradley, on account of persistent pelvic pain, greatly 
 aggravated at each period, and which no treatment relieved. I 
 could find nothing on examination, and I had very great mis- 
 givings about operating in a case where the conditions were 
 purely subjective. I opened the abdomen, however, and found 
 both ovaries and tubes adherent. The tubes were occluded, and 
 the outer extremity of each was occupied by a small chronic 
 abscess, which amply accounted for all the symptoms. The 
 preparations are now in the museum of the College of Surgeons. 
 The patient has made an excellent recovery. 
 
 The features common to these cases are (1) a history of severe 
 pelvic inflammation, though sometimes this cannot be ascer- 
 tained with precision. Its origin is variously ascribed as from 
 gonorrhoea, a chill, or sudden stoppage of menstruation, and 
 (most frequently) inflammation after labor or a miscarriage. 
 There is always (2) pain, which comes on after exertion, and 
 especially after intercourse, and generally becomes intensified 
 when menstruation appears. At this time the pain is often 
 described as excruciating, and it lasts throughout the period. In 
 the majority of instances there is (3) irregular and profuse men- 
 struation, often amounting to hemorrhage. 
 
 The physical signs are (1) swellings at the seat of the ovaries, 
 which are always tender and generally quite fixed. Distinct 
 fluctuation can often be felt, and their peculiar sausage-like 
 shape has frequently enabled me to diagnose correctly the con- 
 dition previous to the operation. 
 5
 
 06 DISEASES OF THE OVARIES. 
 
 No treatment whatever relieves these cases, save removal of 
 the uterine appendages. 
 
 Most of my cases had been in the hands of some of our most 
 eminent specialists before they came to me,, and an infinite va- 
 riety of treatments, both by drug and operation, had been used 
 fruitlessly. They had all been treated by pessaries, and many 
 of them had had their cervical canals dilated and cut. 
 
 Tapping the dilated tubes is of no use and is extremely diffi- 
 cult. 
 
 At the operation the organs are nearly always found matted 
 to the pelvic wall and to intestines, and their removal is often 
 extremely difficult — far more difficult than removal of an ova- 
 rian cystoma. I always remove the ovaries along with the 
 tubes, as without the ducts the glands are, of course, useless. 
 
 All my patients — twenty-two in number — have recovered, and 
 of those in which a sufficient time has elapsed since the oper- 
 ation I can say confidently that they are all completely cured. 
 
 All the cases had been, of course, rendered sterile by the dis- 
 ease, and in most of them the marital function was also de- 
 stroyed. I have not found that the operation has had any other 
 effect than that of restoration of sexual activity where it has 
 been lost. 
 
 Menstruation has, in most cases, been arrested immediately, 
 but in a few it has lingered for a month or two. 
 
 The pathological condition of most importance is practically 
 the same in all these cases, and arises, I think, from an attack 
 of acute or subacute oophoritis or peri-oophoritis. During this 
 process the trumpet-shaped extremity of the tube approaches 
 the ovary for its normal temporary attachment ; and this, by the 
 inflammatory process, becomes permanent. Certain it is that, 
 in nearly all the cases, permanent attachment of the tube to the 
 ovary is to be seen. Probably, after the attachment has occurred, 
 the inflammatory process extends to the tubes, there is a desqua- 
 mation of the ciliated epithelium, and occlusion of the tube at its 
 uterine extremity occurs. 
 
 The nature of the contents of the tube is determined by causes 
 which I do not understand. The most common of the varieties 
 of this disease is hydrosalpinx, and the rarest is hsematosalpinx. 
 
 In connection with these cases I may refer to a curious series 
 of phenomena which has repeatedly fallen under my notice, 
 and which, I gather from the writings of other observers, has 
 also been noticed by them. Thus, in several cases where I have 
 opened the abdomen for the purpose of removal of the ovaries 
 on account of severe and intractable pelvic pain, I found the 
 organs matted together with all the appearances of old pelvic
 
 ERRORS OF DEVELOPMENT OF OVARIES AND OVIDUCTS. 67 
 
 peritonitis — so much so that I have been unable to complete the 
 operation. I have also, as I have already stated, found in very- 
 many instances the Fallopian tubes occluded and distended with 
 fluid which, in several cases, was purulent. Looking back 
 upon the histories given by some of the patients in whom I was 
 unable to complete the operation, I have found distinct state- 
 ments made of recurrent attacks of severe pelvic inflammation. 
 I have also noted, in some of them who had been under my care 
 for prolonged periods, that at some of my examinations I found 
 distinct tumors on one or both sides of the uterus, while at other 
 examinations no trace of these tumors could be seen. Speaking 
 of an absolutely similar experience, Dr. Mathews Duncan says : 
 •'After a time the tumor disappears. Frequently its disappear- 
 ance is accompanied by adhesive perimetritis. Now, what has 
 happened in these cases ? Of course it may be said that it is a 
 case of mere ignorance, or that the C3^sts were parovarian ; but, 
 to this latter exi^lanation there is, for me, the great objection 
 that the cases occur more frequently by far than to admit of 
 their being justly so explained. "We must suppose, therefore, 
 the bursting of the not infrequent small follicular dropsies. I 
 would further add that the bursting of simple parovarian cysts 
 does not appear to me to be followed by perimetritis, or accom- 
 panied by it, so generally in the case of the disease of which I 
 have been speaking." 
 
 In only one of my cases have I seen reason to accept Dr. Dun- 
 can's explanation, that is to say, in only one of them have I found 
 the small cyst of the ovary (which was probably on the point of 
 bursting), and elsewhere in the ovaries, distinct evidence that 
 similar ruptures had occurred before. I feel perfectly certain 
 that in some of the cases there can be no doubt that Dr. Dun- 
 can's explanation is the correct one ; but I have so much more 
 frequently found the Fallopian tubes at fault, that I am inclined 
 to believe that in the great majority of these cases of recurrent 
 pelvic peritonitis, due to rupture of a cyst, it is in the tubes that 
 we shall find the origin of the mischief. 
 
 Looking at some of my preparations of hydro- and pyosal- 
 pinx, I find it difficult to resist the conclusion that periodic rup- 
 ture of the distended infundibulum is a somewhat frequent 
 occurrence in them. It is, of course, very likely that in many 
 cases a cure is effected in this way ; but in others the disease is 
 only aggravated, and probabh' in many the rupture is fatal. In 
 a discussion which took place at a meeting of the American 
 Gynecological Society in 1880, 1 find a corroboration of my views 
 in some of the remarks of my friend. Dr. James R. Chadwick, of 
 Boston. He speaks as follows : ""ISrow I have had several cases
 
 68 DISEASES OF THE OVARIES. 
 
 presenting a similar succession of symptoms, in which I have 
 been able to detect a cyst on one side or the other of the uterus, 
 which I have diagnosticated as a cyst of the Fallopian tube, but 
 have never verified my opinion by operation or autopsy. My 
 explanation of the symptom is this : that fluid collects in the 
 tubes, of which the fimbriated end is occluded until it is greatly 
 distended ; as the monthly period approaches, peristaltic action 
 repeatedly occurs in the tube, attended with great pain, which 
 tends to expel the fluid through the uterine end temporarily oc- 
 cluded. This action continues at intervals with increasing vio- 
 lence, until, during the catamenial relaxation of the uterus, the 
 fluid contents of the tube are forced through the opening into the 
 uterine cavity, with immediate relief. If this view be correct, 
 the removal of the ovaries was of no consequence, though the 
 operation was quite as urgently called for, as the best and per- 
 haps the only means of relieving the cystic condition of the 
 tubes, and securing to the patient immunity from her suffering,'' 
 
 A patient who had been under my care for some months died 
 suddenly a few weeks ago, and the pelvic organs were obtained at 
 the post-mortem examination. She came under my care in Jan- 
 uary last, as an out-patient at the Women's Hospital, with symp- 
 toms of chronic metritis, including severe menorrhagia. On 
 April 28tli I recognized the presence of a small cyst on the right 
 side, as large as an orange. At the end of May she had an attack 
 of pelvic peritonitis. On June 13th the tumor had disappeared. 
 On August loth it had returned, and it again disappeared in 
 September, its disappearance being accompanied by inflamma- 
 tory symptoms. On October 10th it was again to be felt, and 
 about the 30th she died, and Mr. J. Garman, of Wednesbury, ob- 
 tained the preparation for me when I told him that she had a 
 bursting pelvic cyst. Mr. Alban Doran has examined the prepa- 
 ration, and confirms my opinion that the cyst is the right Fallo- 
 pian tube. Doubtless many a mysterious case of peritonitis 
 arises from some such cause as this. 
 
 Thus it will be seen that recent advances in pelvic surgery, 
 by which we are enabled to deal with a great number of cases 
 which formerly were left to unrelieved suffering, and often to 
 inevitable death, have made it clear that there are very many 
 cases in which the tubes, having become occluded by acute or 
 chronic inflammation, are occupied by purulent fluid — a condi- 
 tion which can be remedied by surgical operation alone. 
 
 In its acute stage inflammation of the tubes is a most formi- 
 dable disease, and so rapidly ends in general peritonitis that we 
 can hardly recognize the necessity for interfering before it is too 
 late to do anything. I have seen several fatal cases of peritoni-
 
 ERROES OF DEVELOPMENT OF OVARIES AND OVIDUCTS. 09 
 
 tis which undoubtedly had their origin from inflammation of 
 the Fallopian tubes, and which ought to have been treated by 
 abdominal section. Indeed, I do not think I shall again will- 
 ingly allow a case of peritonitis to die without an effort to save 
 her by an operation. I am fully persuaded that we might save 
 many such cases by boldly opening the abdomen and cleansing 
 its cavitj^ In three cases of chronic peritonitis I have done this, 
 and cured the patients completely. 
 
 Pyo-salpinx is, however, a more chronic condition, some of 
 the cases upon which I have operated having lasted over several 
 years. Probably they all arise in some acute inflammation 
 which occludes both openings of the tubes, and converts one or 
 both — generally both — into chronic abscesses ; yet in the last 
 case I have narrated there was in the history no incident of an 
 acute kind. Dr. S. Wilks has met with two cases where pyo- 
 salpinx caused general pysemia, one case proving fatal from an 
 abscess in the liver, the other from an abscess in the brain. 
 
 Besides pus, we occasionally find that an occluded Fallopian 
 tube may contain bloody fluid {licEmato-salpinx) of menstrual 
 origin. It has been completely established, especially by the ob- 
 servations of Bernutz and Goupil, that the tubes generally share 
 in the secretion of the menstrual fluid, and when the clamp 
 used to be employed in ovariotomy, we constantly saw menstrual 
 weeping from the stump. It is not, therefore, surprising that 
 occasionally we should meet with a case of haemato-salpinx. 
 Dr. Alfred Medows records the post-mortem examination of one 
 in the eighth volume of the '' Transactions of the London Obstet- 
 rical Society," in which " it was found that both Fallopian tubes 
 were enlarged, not regularly and uniformly, but so as to form a 
 kind of cyst. On the right side there were two such enlarge- 
 ments ; on the other, one. There was no evidence of any com- 
 munication between these dilatations and the fimbriated open- 
 ing. On the left side there was not even an opening into the 
 uterus, the ostium uterinum being completely occluded. They 
 were all filled with a dark, thick, grumous fluid, of a prune- juice 
 color. It is evident that, in this case, we have an example of 
 what Bernutz and Goupil contend for — menstrual retention 
 within the Fallopian tube. The one fact which is cleanly re- 
 vealed is, that the Fallopian tubes do. as well as the uterus, take 
 part in the menstrual secretion ; and hence, when any obstruc- 
 tion occurs to the passage of that secretion into the uterine 
 cavity, and so externally, we get the resulting symptoms of 
 menstrual retention."' 
 
 The following case has occurred in my practice, and I have
 
 70 DISEASES OF THE OVARIES. 
 
 fortunately been able to operate on it successfully. The patient 
 remains now (1881) in perfect health : 
 
 Miss M , aged thirty-eight, was sent to me in the begin- 
 ning of 1877, by my friend Mr. Alfred Freer, of Stourbridge. In 
 November, 187G, she had an ill-defined illness, during which she 
 had obscure pelvic pains, accompanied by fever. Previously to 
 this illness she had been in good health, and had menstruated 
 regularly. After it, she had severe pain during the whole pe- 
 riod of menstruation, and she gradually increased in size until 
 Mr. Freer discovered a pelvic tumor in February last. I found 
 tlie tumor to be pear-shaped, quite movable, attached to the 
 uterus at the left cornu, evidently unilocular, and about the size 
 of an infant's head. I diagnosed it as a cyst of the parovarium, 
 and advised that it should be tapped after it had increased in 
 size sufficiently to warrant interference. She returned to me in 
 May, with the tumor increased so as to be felt above the umbili- 
 cus. I advised her to come again in a month. She came, how- 
 ever, before the expiration of that period, on account of a sudden 
 accession of serious symptoms; and when I saw her, on June 20th. 
 there could be no doubt she was suffering from peritonitis. Her 
 pulse was 130; the temperature was 38.4° C. (101.12° Fahr.), and 
 rose to 39. G° C. (103.28° Fahr.) in the evening: and there was 
 excessive pain all over the abdomen, with considerable flatulent 
 distention. I administered opium freely, and applied counter- 
 irritation over the epigastrium. 
 
 On the morning of the 21st she was easier, but the tempera- 
 ture and pulse had not fallen. I therefore had her placed under 
 the influence of ether by Dr. A. H. Carter, and proceeded to open 
 the abdomen, assisted by Mr. Priestley Smith. The tissues of the 
 abdominal walls were extremely vascular, and it was necessary 
 to use a large number of ligatures to arrest the bleeding. The 
 peritoneum was found to be intimately adherent to the tumor, 
 and, as soon as the latter had been laid bare for a short distance, 
 it became evident that it was not an ovarian tumor, but pre- 
 sented the red, muscular appearance of the uterus. Passing the 
 forefinger of my left hand down as deeply as I could in front of 
 the tumor, with that of my right hand in the vagina, I made out 
 distinctly enou^^h that my original conception of the relations of 
 the tumor to the uterus were perfectly correct. Under the sus- 
 picion that it might be a tubal pregnancy, I did not separate the 
 tumor further, as I had not opened the peritoneal cavity, but cau- 
 tiously opened the cyst in the middle line by means of a knife. 
 As soon as I had readied ics inner coat, I passed my small trocar 
 in, and evacuated about six quarts of thick, dark brown fluid.
 
 ERRORS OF DP:VEL0P3IENT OF OVARIES AND OVIDUCTS. 71 
 
 having the peculiar smell of menstrual fluid. After the cyst 
 was emptied, I passed my finger through the hole made by the 
 trocar, and, to my amazement, I found that the cyst had con- 
 tracted ; moreover, as I kept my finger in the cavity, I distinctly 
 felt it contracting round and grasping my finger. Passing the 
 forefinger of my other hand into the vagina, I made out that what 
 I had opened was, beyond doubt, the left Fallopian tube, and that 
 I must have opened it close to its fimbriated extremity. I could 
 find no canal leading into the uterus, and did not deem it advis- 
 able to make one. I washed out the cavity freely with weak 
 carbolic lotion, by reversing the syphon action of my trocar. 
 The wound was closed by four deep sutures, one of which was 
 so arranged as to fasten in a loop of wire drainage-tube ; but be- 
 fore this was done I acted on a hint from Mr. Priestley Smith, 
 and snipped off a piece of the cyst- wall for microscopic exam- 
 ination. This fragment proved to be composed of an abundance 
 of unstriped muscular fibre, conclusively supporting the view 
 that this singular tumor was a distended Fallopian tube. After 
 the operation I treated her exactly as a case of ovariotomy. 
 Her temperature fell slowly. The wound suppurated freely, and 
 shreds of what was undoubtedly mucous membrane came away 
 with the discharge in large quantity. The drainage-tube was 
 removed on the twenty-first day, and its track continued to 
 discharge until the beginning of August. It then healed, and 
 she is now (October 18, 1881) in perfect health. She has never 
 menstruated since the operation. 
 
 From the fortunate issue of this case much is left to specula- 
 tion, but of the nature of the tumor there is no doubt. As to its 
 origin, it seems to me that it may be accounted for by the sup- 
 position that the illness from which all her symptoms dated was 
 a localized salpingitis, which resulted in the closure of the two 
 ends of the tube. The peritonitis, which she undoubtedly had 
 when I operated on her, I suggest was due to a threatening rup- 
 ture of the tube, and possibly a slight escape of its contents. If 
 this be so, it is evident that it was only the accident of my de- 
 termination to act promptly which saved the patient's life. 
 
 Arthur Farre quotes a case of this kind, in which the disten- 
 tion by the menstrual fluid advanced to rupture, followed, of 
 course, by death. I think my case was on the verge of a similar 
 fate. 
 
 Dr. Mathews Duncan has for a long time insisted that occa- 
 sionally the Fallopian tube might be patent so far as to admit 
 the passage of the sound through it. I am bound to say that I 
 have never seen any evidence, from my own experience, that
 
 72 DISEASES OF THE OVAKIES. 
 
 such a condition has occurred, though I have admitted its possi- 
 bility. The cases in which it is stated to have occurred I have 
 always regarded as instances of the passage of the sound through 
 the fundus, an incident to which Simpson drew attention, very 
 many years ago, as of not infrequent occurrence. In the Lancet 
 of 1872, I have reported authenticated instances of this curious 
 fact. In the British Medical Journal of March 12, 1881, Dr. 
 Duncan has published a paper in which he gives some very curi- 
 ous information on the subject of '• Open Fallopian Tube," and 
 though I am still somewhat sceptical, I give the following ex- 
 tract from his paper, in order to draw attention to the subject. 
 That it is not impossible is certain from the fact that in cases of 
 parovarian cysts, where the tube is often wound around the base 
 of the tumor, and greatly increased in length and thickness, it 
 is sometimes possible, with care, to pass a No. 4 or 5 male cathe- 
 ter through the tube. 
 
 "Investigating the pelvic conditions of a case destined by a 
 colleague for ovariotomy, I found the uterine probe pass to the 
 right side of the pelvis, and far beyond the limits of the uterine 
 body, which was easily and certainly felt. When the woman* 
 was on the operating-table, I failed to pass the probe again 
 through the tube, probably from the unfavorable circumstances 
 under which the attempt was made. A few days subsequently, 
 in the post-mortem examination, the right tube was observed 
 lying in the route which the probe had taken, and its uterine 
 extremity was patent — not to the extent of being wide enough 
 to transmit a uterine sound, with its large, bulbous point, but to 
 transmit a common small surgical probe. 
 
 " Interesting evidence of the patency of the tubes is found in 
 the intra-uterine clots discharged in some cases of metrorrhagia. 
 These, coming away as models of the uterine cavity, bear, at 
 their upper angles, long clots drawn out of the tubes, and found 
 hanging from the main intra-uterine clot. Appendages of the 
 same appearance and origin may be found attached to the de- 
 cidua in cases of abortion (see the author's ' Researches in Ob- 
 stetrics,' p. 29G); but these are decidual in structure, and have 
 some strength, and are not extracted from the tube, but are part 
 of the tube. They do not indicate patency; but the extraction 
 of a long clot, so delicate and perishable as it is, attached only 
 by the feeble cohesion of coagulation to the main intra-uterine 
 clot, indicates a decided patency of the canal from which it 
 passed. In Pirie's case {Obstetrical Journal, January, 1880, p. 5), 
 • the upper part of the clot was firm, even somewhat tough, and 
 tlie tubal cords were nearly four inches long.' In the case of 
 C. Rokitansky (ibid., March, 1880, p. 133), the body of the uterus
 
 ERRORS OP' UEVELOPXENT OF OVARIES AXD OVIDUCTS. 73 
 
 contained ' a three-cornered coagulum, ending above, on both 
 sides, in a short, thin thread running to the tubes.' Whitehead 
 (ibid., March, 1880, p. 137) says that, in his case, 'small fibrous 
 prolongations from the clot corresponded to the Fallopian tubes.' 
 
 "■ Of the possible evil results of persistent j)atency of a Fallo- 
 pian tube, the following is an example, related to me by Mr. 
 Hewer, as having occurred in the practice of his partner, Mr. 
 Calthrop. A widow, aged forty-eight, had a polypus of the 
 cervix snipped off by scissors. On the fifth day after the opera- 
 tion her sister gave her, gently, a vaginal injection of warm 
 water with Condy's fluid. While receiving the injection the 
 patient cried out, ' You have killed me,' and was seized with 
 sudden pain in the right side of the abdomen. She lived for 
 three days, in great pain till within a few hours of death. On 
 post-mortem examination there was found general peritonitis, 
 with flaky lymph on the intestines. The right Fallopian tube 
 was seen to be much larger than the left — twice as broad ; it was 
 freely patulous. The section of the pedicle of the polypus was 
 healthy. There were two other polypi in the cervix. Here, as 
 Mr. Hewer says, it was plain that the injected fluid jjassed into 
 the peritoneal cavity through a canalized tube, and caused peri- 
 tonitis and death. Of this accident many cases are now on 
 record, the injections being either vaginal, as in Hewers case, 
 or intra-uterine. 
 
 '• By the same route I have long held that blood frequently 
 passes from the uterine cavity into the peritoneal cavity, and 
 gives rise to hsematocele. Indeed, I incline to the opinion that 
 this diversion of blood, whether menstrual, menorrhagic, or 
 metrorrhagic, is the most frequent cause of this not uncommon 
 disease. Of course it is necessary to suppose, what has been 
 well accounted for, that the morbid course of the blood is me- 
 chanically easier than the natural or ordinary one through the 
 cervix uteri into the vagina ; and there can further be no doubt 
 that, ordinarily, even when a tube is patent, the mechanically 
 ' easier progress of the blood is through the cervix into the vagina. 
 Were it not so, hsematocele would be much more frequent than 
 it is. I have often known a woman lose blood from her uterus 
 per vaginam while a tube was freely patent. 
 
 " Besides the passage of blood, there is the almost certain, 
 but very rare, passage of a lumbricus through a patent tube 
 (Winckel: ' Die Pathologic der weiblichen Sexual-Organe,' S.3-21). 
 This kind of passage is effected by the movements of the animal. 
 
 " Further, openness of a tube is a necessary condition for the 
 accomplishment of the wandering of the ovum in certain cases 
 of extra-uterine pregnancy.
 
 74 DISEASES OF THE OVARIES. 
 
 " In conclusion, it is necessary to remember that, besides 
 natural and morbid conditions of patency, there may be unnatu- 
 ral absence of temporary patency, or of occasional dilatation of 
 the tubes ; for it is probable that they dilate during sexual ex- 
 citement, and permit the passage of the semen. Indeed, it is 
 scarcely conceivable that semen can permeate the tubes while 
 they are in their usual closed state. This absence of dilatability 
 of the tubes, or their rigidity, may thus be a cause of barren- 
 ness. 
 
 " The proposition of Tyler Smith to catheterize the tubes, and 
 thus cure sterility, was brought forward under the influence of 
 different theoretical views from those expressed in this paper. 
 It has, as yet, led to no more practical result than the proposal 
 of Froriep to close them by cauterization, in order to produce 
 sterility." 
 
 Of course I need hardly say that I regard such views as Dr. 
 Duncan here expresses concerning the passage of semen up the 
 tube as wholly contrary to fact, and quite irreconcilable with 
 what I have already said concerning the physiology of the tubes. 
 
 Simpson relates a case of simple hypertrophy of the muscu- 
 lar coat of the walls of the tubes. Various authors also men- 
 tion tumors as having been found in their substance, but the 
 majority of these cases' are not described with sufficient mi- 
 nuteness of anatomical detail to enable us to accept them im- 
 plicitly. Myomata of small size, as we might expect from the 
 structure of the tubes, have been repeatedly found, and about 
 their occurrence there can be no doubt. Cancer and tubercle 
 extend into the tubes from the uterus ; but we may dismiss all 
 these conditions by saying that their diagnosis is impossible, 
 and that it would be of little importance if it could be made. 
 
 Occasionally calcareous concretions have been found in the 
 tubes, possibly the result of old, chronic abscesses. The clinical 
 history of such cases is never given. The organ of Rosenmiiller, 
 a small cyst which remains from the ducts of the Wolffian body, 
 is a curious feature of the outer part of the tube. I believe that 
 sometimes it undergoes cystic enlargement, and should be treat- 
 ed as an ovarian tumor. In one of my recent ovariotomies I 
 found it to be about four or five times its usual size, and I re- 
 moved it. 
 
 One of the most important abnormalities of the Fallopian 
 tube is that in which the ovum comes in contact with spermato- 
 zoa during its passage through the canal, becomes adherent to 
 its walls, and develops into a Fallopian pregnancy. This acci- 
 dent occurs probably when the ciliary action of the mucous lin- 
 ing is destroyed by some desquamation or other accident, for I
 
 EKKOUS OF DEVELOPMENT OF OVARIES AND OVIDUCTS. 75 
 
 have already stated that I do not believe that impregnation takes 
 place in the tubes save under exceptional circumstances, and 
 when it does occur the probabilities are great that the fertilized 
 ovum will there contract the adhesions which it ought to have 
 in the uterus. When this misfortune does occur, the tube ex- 
 pands to a certain limit, that limit being reached between the 
 second and third months of pregnancy, at which time rupture 
 usually takes place. In the vast majority of cases that rupture 
 is fatal, and I am sure that there is no experienced gynecologist 
 who has not seen at least several instances of it. I have known 
 at least twenty post-mortem examinations of women who have 
 died from ruptured tubes. In not a single instance which I 
 have seen, nor in any of which I have found record, has the 
 pregnancy been anywhere but in the tube. The cause of death 
 in these cases of tubal rupture is invariably hemorrhage, and 
 the source of hemorrh^ige is the enlarged maternal vessels at 
 the site of the placenta. Unfortunately, it is just here that the 
 rupture nearly always occurs, because the tissues are thinner, 
 more vascular, and more easily torn than elsewhere. These 
 facts I was able abundantly to prove in a case which I at- 
 tended with my friend Mr. Hall- Wright, in which I removed 
 the parts en masse, and succeeded in injecting them perfectly. 
 Occasionally this rupture takes place without hemorrhage, or at 
 least without fatal hemorrhage, and the patients survive the 
 accident. In what percentage this fortunate issue occurs we do 
 not yet know, but it is probably not large. By the rupture the 
 ovum is extruded into the peritoneal cavity or between the 
 layers of the broad ligament, the latter being an exceptional and 
 a very favorable occurrence, because the patient is not likely to 
 die of the hemorrhage. 
 
 It was after the dissection of a case of this kind, described by 
 Dezeimeris as " subperitoneo-pelvic " (his second variety ''sous- 
 peritoneo-pelvienne"), that I was led to reconsider the whole 
 question of the pathology of this important subject. Up to that 
 time we had accepted the involved classification of the author 
 I have just quoted, who made out ten different varieties. Grow- 
 ing experience and the consideration of a large number of re- 
 corded cases have, however, induced me fully to adopt the view 
 of the origin of all cases of extra-uterine pregnancy which I first 
 laid before the Obstetrical Society of London in 1873. Of this 
 view the late Dr. John S. Parry, in his exhaustive treatise on 
 the question, says : "In opposition to this minute anatomico- 
 pathological classification of Dezeimeris. we have the simple one 
 of Mr. Lawson Tait, who asserts that there are only two forms of 
 misplaced conception. In one the oviduct bursts, the peritoneum.
 
 76 DISEASES OF THE OVAKIES. 
 
 remaining uninjured, after which the ovum escapes into the 
 broad ligament, between the folds of which its development 
 continues. In the other variety the peritoneum is lacerated, as 
 well as the walls of the tube, and the ovum finds its way into 
 the cavity of the abdomen. The first is the subperitoneo-pelvic 
 pregnancy of the French authors, and the latter is the secondary 
 abdominal pregnancy of Boehmer. 
 
 " Prof. T. G. Thomas, of New York, has recently promulga- 
 ted opinions in support of those of Mr. Tait. He writes (New 
 York Medical Journal, June, 1875): 'I feel inclined to believe 
 that, in the commencement of its development, the impregnated 
 ovum never attaches itself to or draws its nourishment from 
 any other parts than those lined by the mucous membrane of the 
 uterus or tubes. Knowing, as we do, the delicate and subtile 
 connection which the chorion establishes with the maternal tis- 
 sues, it is certainly difficult to believe that an impregnated 
 ovum, falling free into the peritoneal cavity, or detained within 
 the Graafian vesicle, can, with parts so unlike the lining of the 
 uterus, establish relations almost identical with those which are 
 nornicil.' " 
 
 These opinions of Prof. Thomas are quite in accord with my 
 own, and it has further always seemed to me that the idea that 
 an ovum could be impregnated in the ovary and then pass, not 
 through the Fallopian tube, but into the peritoneal cavity, and 
 then out through the membrane into the tissue of the broad 
 ligament, was alike improbable and far-fetched. It was much 
 more likely, and the dissection in my case made me certain, that 
 this exceptional form arises merely from the rupture of the tube 
 in an ordinary tubal pregnancy, the wall giving way at the 
 lower part, and allowing the ovum to extrude into the connective 
 tissue between the two layers of the broad ligament. This con- 
 viction led me still farther. It made me examine other cases of 
 wliich I had the preparations, or which I met with in practice 
 subsequently, with great care, and I became convinced that in 
 every instance the pregnancy was tubal originally, and that 
 the acquired relations of the ovum depended entirely on the 
 accidents of the direction and extent of the rupture of its en- 
 velopes. 
 
 Of course some sub-varieties may be made out of the position 
 of the original attachment of the ovum in the tube, but these can 
 be referred to only in specimens of the displacement in an early 
 stage. In the later stages of the pregnancy all such distinctions 
 must certainly be lost, unless it be that which has been termed 
 interstitial. 
 
 The varieties which may thus be made are three in number :
 
 ERRUllS OF DEVELOPMENT OF OVARIES AND OVIDUCTS. 77 
 
 (a), tubo-ovarian, when the ovum has been fertilized in the in- 
 fundibulum before the separation has occurred between that 
 structure and the surface of the ovary ; {b), tubal ; and (c), inter- 
 stitial, where the attachment has been formed to that part of the 
 tube lying in the uterine wall. 
 
 There can be no doubt that the former variety has been accu- 
 rately described and fully established, but of the so-called ova- 
 rian pregnancy I shall have something to say in the chapter on 
 ovarian tumors. 
 
 The interstitial variety is very likely to be far more common 
 than we have hitherto suspected, for there is little doubt that it 
 can and does end by natural labor at the full term. (See John 
 S. Parry's scholarly and complete treatise.) 
 
 This distinction of varieties. has, however, but little practical 
 importance, save, perhaps, in being associated with a like distri- 
 bution of the frequency of disastrous rupture of the structures, 
 and death by hemorrhage. One would expect that the tubo- 
 ovarian variety would be most likely to have this occurrence, 
 and that the interstitial variety would be the least likely ; but 
 there are no established data upon which to make any state- 
 ment. 
 
 It is at any rate certain that when an impregnated ovum at- 
 taches itself to any part of the tube outside the uterus, rupture 
 of some of the structures will take place before the fourth month, 
 probably very much earlier. If the extrusion takes place into 
 the abdominal cavity, the membranes may either remain entire 
 and be developed with the foetus, or they may rupture, and the 
 foetus will then float loose in the cavity of the abdomen. Mean- 
 while the placenta retains its old attachment to the inner surface 
 of the tube, which becomes everted, and it likewise acquires new 
 attachments, as it grows, to the front of the rectum, ovaries, 
 various parts of the peritoneal surface, and even to the small 
 intestines. Wherever it may attach itself, it displays a marvel- 
 lous power of sending villi into the structures, and inducing an 
 enormous enlargement of the vessels in the neighborhood. 
 These enlarged vessels, as I have seen on injection, appear more 
 like sinuses than ordinary vessels. Their walls are very thin 
 and have no distinct muscular layer, a fact which at once ex- 
 plains the disastrous results which have always followed at- 
 tempts to remove the placenta in operations for extra-uterine 
 gestation, the hemorrhage being quite uncontrollable. It also 
 explains the profuse hemorrhage which follows a compara- 
 tively insignificant rupture of an organ not usually very vas- 
 cular. 
 
 It will be seen, therefore, that I maintain that every case of
 
 78 
 
 DISEASES OF THE OVARIES. 
 
 extra-uterine pregnancy is tubal in its origin, and that it may 
 become intra-peritoneal or extra-peritoneal, just as the tube hap- 
 pens to burst. The intra-peritoneal termination is beyond all 
 question the more common and the more fatal ; while the extra- 
 peritoneal development of the ovum is much rarer, less fatal, 
 and, what is of more consequence, far more amenable to treat- 
 ment. 
 
 The diagnosis of extra-uterine gestation in its early stage is 
 
 Fatal Case of Fallopian Pregnancy at Eighth Week (after Duguet). 
 
 Fig. 22. — A, Uterus laid open on the anterior Bnrface ; B, part of the decidua Ktill adherent to the ri^ht 
 uterine cornu : C. decidna, nearly entire, e.vpelled before death; i>, rit;ht tube and ovarj'. miruial: E. E, 
 marsrin-s of artificial opening in the left tube ; F. umbilical cord ; G, placenta; H, pavilion of the left tube ; 
 /, vascular ple.xus, ramifying over ihe tubal covering of cyst, from which the hemorrhage occutb on its rup- 
 ture : t/, vagina. 
 
 Fig. 2.3.— .1. View of the posterior surface of the utenis : B, fimbria; of left tube; C, C, C, rents ni 
 tul-al covering of cyst, corresponding to site of placenta, from which the foetus escaped and hemorrhape 
 came; i>, ovary attached to lower surface of cyst, and increased in size ; E, right tube. 
 
 surrounded with difficulties, and we are seldom called upon to 
 consider it until nearly all hope of successful interference is over. 
 I refer, of course, to the class of cases which we see at the time 
 of the tubal rupture, and which are generally included under 
 the head of intra-peritoneal htematocele.
 
 ERRORS OF DEVELOPMENT OF OVARIES AND OVIDUCTS. 79 
 
 I have very little doubt, however, that inan}^ of these cases 
 would be saved by prompt action. The difficulty is, of course, 
 in the diagnosis, some certainty of which is requisite before an 
 abdominal section can be performed. I have twice been on the 
 point of performing abdominal section on account of suspected 
 rupture of a Fallopian tube, and have been prevented by scruples 
 as to the correctness of the diagnosis. In both cases post-mortem 
 abdominal section showed that the suspicion was correct, and I 
 believe both of these patients might have been saved. A hesita- 
 tion in opening the abdominal cavity was natural enough when 
 we were overburdened with the superstition that it was a very 
 serious step; but now that we know it can be done with perfect 
 safety, I would not hesitate to explore in a case where I sus- 
 pected a Fallopian rupture. If my suspicion were verified, I 
 would apply a ligature to the rupture after I had completely 
 emptied the sac, or I would completely remove the broad liga- 
 ment, or perhaps stitch it to the abdominal wound, and drain it, 
 as I have done with pelvic abscesses, dropsy of the gall-bladder, 
 hydrated cysts of the liver and kidney, etc. In this way I think 
 some of these terrible cases might be saved. 
 
 I have chiefly to speak of the cases which survive this first 
 and greatest risk of death from hemorrhage. Usually we do not 
 see them until some months after the time of their expected con- 
 finement, and after the child has died. In very rare instances 
 our assistance is asked before this period, and in these the ut- 
 most care must be exercised before the diagnosis is acted upon. 
 Of course, if the child is found loose in the abdomen and moving 
 about, the diagnosis is as simple as that of a fractured leg, and 
 the mere division of the abdominal walls will end the displace- 
 ment. Only one such fortunate case is as yet, however, on record 
 — that which recently has been published by Mr. Jessop, of 
 Leeds. 
 
 But supposing that the child is still enveloped in a sac of some 
 kind, and alive, how can we determine that it is not in the uterus ? 
 I confess that, short of introducing the sound or the finger into 
 the cavity, I know of no means of certain diagnosis, and that pro- 
 ceeding can be justified only by urgent symptoms. Since I wrote 
 originally upon this subject, I have repeatedly been called to 
 cases where, for some reason or other, extra-uterine pregnancy 
 with a living child was suspected, but in not a single instance 
 did the result justify the suspicion, and my invariable advice to 
 wait for symptoms always resulted in our waiting for ordinary 
 labor. In one case in the practice of Mr. Langley Browne, of 
 West Bromwich, we found a very thin uterus extremely retro- 
 verted. In the others the conditions were those of extremely
 
 80 DISEASES OF THE OVAKIES, 
 
 thin walls, with some kind of displacement, as latero-flexion or 
 retroflexion, and in these patience always solved the doubts. If 
 I met with a case where any urgent symptoms existed, I would 
 not hesitate to use the sound or use my dilators if necessary ; 
 for the worst that could happen, in the event of mistake, would 
 be a premature labor. 
 
 This condition of extreme thinness of the uterine walls, in a 
 pregnancy perfectly normal in every other respect, is a point 
 which has not yet received any notice, so far as I know. It is, 
 however, of sufficiently common occurrence to be a source of 
 difficulty and danger, and therefore I propose to say here what 
 I have noticed about it, in the hope that it may draw the atten- 
 tion of some one engaged in obstetric practice who may be able 
 to investigate it more fully. I can now recall six cases in which 
 I have been consulted concerning a supposed extra-uterine preg- 
 nancy, yet in which there was only an extreme thinness of the 
 uterine walls. I have no record of three of the cases, but of the 
 others I have more accurate data than mere recollection. The 
 features of all, however, had much in common, and the known 
 histories of three quite establish this. The ordinary symptoms 
 of pregnancy were present in all of them, and in only one was 
 there any doubt as to its existence. The question generally was. 
 Is the child in the abdominal cavity? and sometimes I had great 
 difficulty in persuading the gentlemen who brought the patients 
 to me that the position of the child was normal. Save in one 
 case — that seen by me with Dr. Whitwell. at Shrewsbury— there 
 was a marked absence of the liquor amnii, so that the move- 
 ments of the child could be seen and felt in a most striking man- 
 ner. In the pelvis the finger comes upon the presenting part 
 of the foetus, as if it lay immediately under the mucous mem- 
 brane ; and it was only on very careful investigation that the 
 attenuated cervix uteri could be made out, spread over the body 
 of the child. 
 
 These cases were all under the seventh month. In the eighth 
 and ninth months the walls of the uterus thickened, the quantity 
 of liquor amnii increased, and the cases terminated in perfectly 
 natural labors. 
 
 These facts were given to me in connection with Mr. Langley 
 Browne's case, also with a case which was watched by Dr. Hill 
 Norris, and attended by him in her confinement. In Dr. Whit- 
 well's case, which I saw with him last August, there was a large, 
 thin-walled cyst, through which the child could be felt with the 
 most astonishing distinctness, and it floated about as if it were 
 perfectly free in the abdomen. He writes to me that "the pa- 
 tient went on very well, that some time before the expiry of
 
 ERRORS OF DEVELOPMENT OF OVARIES AND OVIDUCTS. 81 
 
 gestation the foetus became much more a fixed body, which un. 
 doubtedly showed an increased thickening of the walls of the 
 uterus, as well as enlargement of the foetus, and that her labor 
 was quick and without any subsequent hemorrhage." 
 
 The other conditions with which extra-uterine pregnancy may 
 be confused, before the death of the child, are (a) displacement of 
 the normally pregnant uterus during the early months of preg- 
 nancy, complicated with fibro-myoma or cystic disease of the 
 uterus ; and, more rarely, (b) pregnancy of one-half of a double 
 uterus. In a case which I saw with the late Mr. Ross, of Wake- 
 field, I diagnosed either extra-uterine gestation or a double 
 uterus with pregnancy of one side, and it turned out to be the 
 latter. Frequently we have considerable lateral displacements 
 of the normally pregnant uterus, especially in unmarried women, 
 sent to the specialist as something very different from what they 
 really are. 
 
 But it is in cases seen after the death of the child, or at least 
 when the time of the expected confinement has passed so long 
 that if there is a child it is sure to be dead, that our most serious 
 difficulties in diagnosis are met with. 
 
 The first point to consider is the history given by the patient 
 of her supposed pregnancy, and the events which occurred at 
 and after the time of her expected delivery. It is somewhat 
 remarkable, and I think it is in favor of the views of the pathol- 
 ogy of tubal pregnancy which I have advanced, that the ma- 
 jority of the instances of this abnormality occur in women who 
 have not borne children previously, or in those who hav^e had no 
 children for many years. This point in the history of the pa- 
 tient is therefore always noteworthy. The other matters requir- 
 ing careful consideration are the sudden arrest of the menses, 
 the gradual increase in size, the occurrence of symptoms of labor 
 at or about the end of the ninth month, and the subsequent dim- 
 inution in size. Of all those points, the last is the only one 
 having the importance of a sign ; but it must always be borne 
 in mind that no history, however complete, is of sufficient v/eight 
 to establish a diagnosis unless there be some distinct physical 
 signs in support of it. This I lay down as a rule based upon a 
 remarkable experience, which I published in detail in the 
 " Transactions of the Obstetrical Society of London " for 1874. 
 In this case I had diagnosed double ovarian tumor, but was comr 
 pletely misled by a subsequent history which the patient volun- 
 teered. This was to the effect that just three years before she 
 had believed herself pregnant, because her menstruation had 
 ceased for eight months, her abdomen had slowly enlarged, and 
 so had also her breasts. She was also quite sure that she had 
 6
 
 82 DISEASES OF THE OVARIES. 
 
 often felt movements, and, indeed, had all the feelings that she 
 had experienced in each of her seven pregnancies. One day, 
 when walking in the street, she was seized with pains, exactly 
 like labor-pains, and these lasted for four hours. At these pains 
 she felt no surprise, fully believing that she was in labor. She 
 felt as if a child was about to pass from her, and was aware of 
 the '• swelling pressing downward." She afterward felt this 
 ''pass back into the belly," the pains ceased, and her size re- 
 mained unaltered. At this false labor there was no discharge. 
 Up to the time when I first saw her she is quite certain no dimi- 
 nution of her size had ever occurred, and that there had been 
 very little increase, if any. 
 
 The physical signs of the case were those of multilocular dis- 
 ease of both ovaries, and on them I need not dwell. I found it 
 was so when I operated, and the operation was successful. The 
 lesson of the case is that we should place very little confidence 
 in the statements of patients, if they are not in harmony with 
 physical signs. I must plead in extenuation, that I never saw a 
 woman farther removed from any taint of hj'steria, and, being 
 an illiterate woman, there could have been no cramming up of 
 s^-mptoms from books. The strongest point in her story was the 
 arrest of menstruation for eight months, and I had corroboration 
 of her statement. 
 
 The weak points in the story were those I did not attach suffi- 
 cient weight to, and they were those alone on which we ought 
 to place any reliance whatever. They are, that she had no 
 •• show*' during the false labor, and that her size did not dimin- 
 ish after it. Having now almost exhausted, I believe, the litera- 
 ture of the subject, I am satisfied that these two circumstances 
 are invariable in extra-uterine gestation which has gone past the 
 l^eriod. The first is due to the general excitement and conges- 
 tion of the organs involved, specially to the enlargement of the 
 uterus, which is always present to some extent ; and the second, 
 to the absorption of the liquor amnii after the death of the child. 
 The complete arrest of menstruation during the period corre- 
 sponding to normal pregnancy is far from being a constant con- 
 dition. But even though it were, like its accompanying signs, 
 such as enlargement of the breasts, darkening of the areolae, 
 increase of Montgomery's tubercles, malaise, vomiting, etc.. it 
 would help us to do little more than suspect a pregnancy. Some- 
 times there is metrorrhagia, due to the large size and empty 
 condition of the uterus, a symptom which would" incline us to 
 the diagnosis of uterine myoma. After the death of the child, 
 auscultatory signs cannot, of course, be made available; though 
 in one of my cases, where the child was clearly dead, the pla-
 
 ERRORS OF DEVELOPMENT OF OVARIES AND OVIDUCTS. 83 
 
 cental sound was heard at my first visit, but had disappeared 
 entirely at my second, ten hours afterward — a set of signs which 
 tended to confirm my diagnosis. 
 
 The invariable condition of the uterus in extra-uterine preg- 
 nancy, whether before or after the death of the child, is that it 
 is intimately associated with the tumor, generally in front of it, 
 movable to a limited extent, always enlarged before the death 
 of the child, and remaining so afterward if the placenta be at- 
 tached, as it generally is, to the posterior surface of the fundus. 
 The most important point is that the cervix is always quite 
 open — in my cases almost admitting the finger. Under such cir- 
 cumstances, if a fetal heart is audible, the case is clear. If not, 
 then the character of the tumor must be taken carefully into ac- 
 count. If the case is seen soon after the death of the child, the 
 tumor will be soft, more or less obscure ballottement will be felt 
 in it, and possibly a part of the child may be made out by rectal, 
 vaginal, or supra-pelvic examination. It is at this stage that 
 the difficulty between extra-uterine gestation and hcematocele 
 will occur. Hsematoceles are not all formed quite suddenly. I 
 have seen several cases where a monthly addition was made to 
 the effused blood. In one such case, during the formation of 
 a large heematocele, menstruation was entirely suspended, or 
 rather its external indications were. The tumor subsequently 
 suppurated and discharged through the rectum, and for a while 
 it really was a grave question to decide whether it was a suppu- 
 rating hsematocele or the suppurating cyst of an extra-uterine 
 pregnancy. I made an exploratory incision into it from the va- 
 gina, and satisfied myself that the former alternative was the 
 correct one, and it is now in process of cure. Periodically increas- 
 ing retro-uterine hsematocele may easily be mistaken for extra- 
 uterine pregnancy in the later stages, and vice versa. 
 
 After the absorption of the liquor amnii, the character of the 
 tumor in extra-uterine pregnancy alters very much. The uterus 
 may become smaller and more mobile, and parts of the child may 
 be felt, especially in the rectum, such a sign at once pointing out 
 the nature of the case. This will be particularly evident in the 
 instances of the extra-peritoneal variety. These prominences, 
 and likewise the *'•' bosselures." or knobs of the hands and feet, 
 which are often felt above the pelvis, may be closely imitated 
 by the small nut-like cysts of small ovarian tumors, and espe- 
 cially by the hard irregularities of dermoid cysts. These re- 
 semblances existed in the case I have narrated above to a con- 
 siderable extent, but to a very much more marked degree in 
 another patient, where I removed both ovaries — one dermoid — 
 but where the resemblances, fortunately, did not lead me astray.
 
 84 DISEASES OF THE OVARIES. 
 
 If the cyst be packed down in the pelvis, the deception may be 
 great, and nothing but an exploratory incision will clear up the 
 case. I would strongly recommend that, in such cases, the aspi- 
 rator should not be used. In a joint, or in the pleura, where the 
 conditions between which diagnosis has to be made are limited 
 in number, this instrument is doubtless of great use, as it is for 
 treatment as well. But in the abdomen and pelvis it is very dif- 
 ferent. The aspirator may tell you a tumor contains serum, 
 blood, or pus, but that helps you but little as to the seat of the 
 disease, and nothing at all as to its treatment. Besides, the risk 
 of the aspirator is great, quite as great as the risk of an abdomi- 
 nal section. My use of the aspirator in my special line of prac- 
 tice is therefore diminishing, and in all cases of abdominal tumor, 
 where there seems a reasonable prospect of doing good to the 
 patient, I open the abdomen and make out the condition. I 
 have never had to regret this practice, and I very often have had 
 reason to be pleased with its results. 
 
 Slow-growing cancer of an ovary, or in the neighborhood of 
 the uterus, especially behind it, might be difficult to diagnose by 
 physical signs from extra-uterine pregnancy of long standing, 
 but the history would here greatly help us. The increase would 
 probably be steady, and if a rapid accession to the growth took 
 place, a temperature chart would settle the difficulty ; for the 
 only condition which could induce rapid increase of the cyst of 
 an extra-uterine pregnancy is suppuration, and this would tell 
 its story on the chart in lines that could not be mistaken. Any- 
 thing else might safely be set down as cancer. Fibro-cystic 
 disease of the uterus could be determined as a tumor of the 
 uterus. Phantom pregnancy can always be dispelled by an an- 
 aesthetic. 
 
 After the diagnosis of a case of extra-uterine pregnancy has 
 been satisfactorily determined, the question arises. What is to 
 be done with it ? If the child is still alive and near the full term, 
 I believe it to be our duty to operate. If the child is dead, the 
 propriety of operating seems to me quite evident, though it has 
 been disputed by so eminent an authority as Mr. Jonathan Hutch- 
 inson. Of course no strict rule can be laid down, and each case 
 must be decided on its own merits ; but the records of surgery 
 are so full of instances of the risks which such cases have to run 
 when suppuration of the sac occurs, as it almost always does 
 some time or other, that I think we are in most instances justi- 
 fied in operating. Moreover, the surgical principles on which 
 the operation is to be conducted are now so well established, and 
 its results are so good, that the opponents of the operation seem 
 to me to be in a very illogical position if they still continue to
 
 ERROKS OF DEVELOPMENT OF OVARIES AND OVIDUCTS. 85 
 
 advocate certain other surgical proceedings, of which the results 
 are notoriously bad. Whether the child be dead or not, the steps 
 of the operation do not vary, and the only condition which would 
 modify my procedure would be a certainty that the foetus had 
 been developed outside the peritoneum, in the layers of the broad 
 ligament. There can, however, be no certainty of this until after 
 an exploratory incision in the median line of the anterior ab- 
 dominal wall has been made, so that we may say that, in every 
 case, abdominal section is the first step; and here the same strict 
 precautions must be observed as in ovariotomy. 
 
 After the peritoneum has been opened, a careful inspection 
 of the relations of the ovum must be made, for the further steps 
 of the operation will differ materially according to the nature of 
 these relations. If the child is loose in the abdomen, it merely 
 requires careful removal, careful avoidance of the placenta, and 
 the closure of the wound in the abdomen save at the lower part, 
 through which the umbilical cord must be drawn, and which 
 must be kept open for the passage of the placental debris after 
 it has separated, through a wide glass drainage-tube inserted 
 for the purpose. The discharge must be drawn up by means of 
 a syringe, three or four times in the twenty -four hours, and the 
 cavity occasionally washed out with a five or ten per cent, solu- 
 tion of sulphuret of potassium, or some other harmless disin- 
 fectant. 
 
 If the foetus is found in a sac which is not covered by peri- 
 toneum, that is, which is not formed by the folds of the broad 
 ligament, the sac must be carefully opened in the middle line, 
 emptied and cleaned out as well as possible, and then its edges 
 must be stitched round to the edges of the wound in the abdomi- 
 nal wall, so as to close the peritoneal cavity as well as possible. 
 The lower part of the wound, communicating with the sac only, 
 must as before be left open, and through it the cord must be 
 brought and the placental debris must pass. I have had six suc- 
 cessful cases of this kind, most of which are recorded in detail 
 in the " Transactions of the Royal Medico-Chirurgical Society." 
 If, however, the sac be found to be covered by peritoneum, that 
 is, if the case is one of the extra-peritoneal variety, I believe that 
 a different method might be followed if possible. In such a case 
 the peritoneum will be found lifted up from its usual relations, 
 so that it runs on to the walls at a much higher level than is 
 usual. In this way an exit for the foetus by way of the vagina 
 is possible, subject to certain conditions, which are that the pla- 
 centa is not to be cut through, and that the passages must be 
 large enough to allow the child to pass. In a case which I oper- 
 ated on by removing the foetus through an incision from the
 
 86 DISEASES OF THE OVARIES. 
 
 vagina, behind the uterus, everything was favorable; but, unfor- 
 tunately, in ignorance I removed the placenta, and the result was 
 fatal. If these conditions are not possible, then the foetus must 
 be removed from above, and the sac must be treated as already 
 described. I am bound, however, to say that I am not in any 
 way in favor of vaginal section. I have never resorted to it but 
 once, in the case before alluded to. and my growing experience 
 makes me think that abdominal section is in ever}^ case prefera- 
 ble. The golden rule for this operation is to avoid touching tlie 
 placenta.
 
 CHAPTER III. 
 
 OOPHORITIS AND PEEI-OOPHORITIS — CIRRHOSIS OF THE 
 OVARY— ABSCESS OF THE OVARY. 
 
 Organes genitaux internes de la femme. Guerin. Annales de Gynecologie. V. XIL 
 
 Affections de I'aprareil utero-ovarien. Fourcauld. Paris, 1879. 
 
 Ovarien bei Scharlach. Lebedinskt. Cent, fiir Gynekologie. V. I. 
 
 Die Krankheiten der Ovarian. Oi-sn.vusEN. Stuttgart, 1877.. 
 
 Ein Fall von Abscessbildung. HuFFELL. Archives f. Gyn. V. IX. 
 
 Balneotherapie im Entziindung der Ovarium. FLECnsiG. Schmidt's Jahrbuch. V. 
 
 170. 
 Veranderung des Ovarium als Ursache d. Sterilitat. Bandl. Schmidt's Jahrbuch. 
 
 V. 178. 
 Augenschmerz bei Affectionen der Ovarium. 
 
 Douleur de I'ovaire chez les ferames enceintes. BuDiN. Progres Med., 1879. 
 Ovarian Pain during Pregnancy. CiiAiGNOT. Med. Record, 1879. 
 Abscess of both Ovaries. Cullingworth. Obstet. Soc. Trans. 
 Pathology of the Ovaries. Mathews Duncan. Med. T. and G., 1875. 
 Clinical Lecture on Ovaritis. Mathews Duncan. Med. T. and G., 1879. 
 Ovarite a la suite d'une rougeole. Lize. Annales de Gyn. V. V. 
 Tubercles des ovaires. Talamon. Annales de Gyn. V. VI. 
 Diagnosis of Subacute Ovaritis. TiLT. Obstet. Trans. Vol. XV. 
 Chronic Ovaritis. TnoMAS. New York Med. Jour. V. XIX. 
 General Peritonitis — Ovaritis with Abscess. LusK. Amer. Jour, of Obstetrics, Jan., 
 
 1879. 
 Uterine and Ovarian Inflammation. TiLT. London, 1863. 
 Ovarite. C. Darolles. Paris, 1876. 
 
 The accession of puberty alters the nutrition of the ovary to 
 the extent that, at the monthly periods, it shares in the general 
 state of hypersemia and excitement then common to all the 
 sexual organs, and the whole economy seems to participate 
 in the disturbance. Normally, this change takes place in the 
 fourteenth or fifteenth year of life in this country ; at an earlier 
 date in hot climates. In strong, healthy girls, especially those 
 engaged in active out-door work — still more those living a life ap- 
 proaching to the primitive state — the moliminal change is effected 
 without suffering ; but in girls brought up in refinement, of deli- 
 cate habit and strumous parentage, there is much trouble. As a 
 rule, this seems to be due to the onset of menstruation, and the
 
 88 DISEASES OF THE OVARIES. 
 
 other signs of the change while the ovary is still in its infantile 
 or incompletely developed condition ; that is, while it is forming 
 incomplete cells, whose nuclei are incapable of fulfilling their 
 great functions, and the whole mechanism of ovulation is out of 
 gear. In such cases we find that the' menstrual flux comes on 
 either at irregular times or in insufficient quantity: or that, if it 
 comes regularly, it is over-abundant, and it is always accom- 
 panied by severe pelvic pain. 
 
 There is a large class of ovarian disease due to altered lisemic 
 nutrition of the gland, which clinical experience proves to be far 
 more common than pathological investigation has yet shown. 
 Of the prime factors in these cases we are as yet comparatively 
 ignorant ; but the opportunities now afforded us of seeing the 
 actual lesions of the ovaries, in those cases where they are re- 
 moved for diseases other than large cystoma, are rapidly open- 
 ing up some of the most difficult questions of ovarian pathology. 
 Until two or three years ago, when Keith's success in ovariotomy 
 induced us to extend our efforts in abdominal surgery, we knew 
 no more of those obscure diseases of the ovary which make the 
 lives of so many women burdensome, than was afforded by the 
 evidence of a few stray post-mortem examinations. A« the clin- 
 ical histories of the cases in which these examinations were 
 made were usually entirely absent, it is not surprising that we 
 knew little or nothing of the pathology of the ovaries, save in 
 the instance of cystoma. 
 
 So far as my own experience goes, I think I can now say 
 with confidence that I know a great deal more than I did three 
 years ago, not only of the pathology of the ovaries, but how to 
 cure the sufferings inflicted by their diseases. 
 
 I propose to retain the division of the diseases of the ovaries 
 due to alteration in the hsemic nutrition, which I introduced 
 nearly ten years ago, and therefore I divide them into three 
 groups, differing probably only in degree of severity, save in the 
 cases where acute ovaritis has a specific origin. They are : 1. 
 Ovarian hypersemia ; 2. Acute ovaritis ; 3. Chronic ovaritis. 
 
 It may seem a metaphysical refinement to make a distinction 
 between the first and second of these classes, but I have long 
 satisfied myself that it actually exists. Ovarian liypersemia is 
 the result of an over-sufficient and generally precocious ovarian 
 activity, and is, therefore, the converse of the condition I have 
 detailed under the terms amenorrhoea and dysmenorrhoea. It is 
 far from being a rare affection, and is invariably well marked 
 in its history, the chief detail of which will generally be found 
 to be menorrhagia. In a typical case which I have now under 
 my care, the following is a summary of the facts : The young
 
 OOPHORITIS AND PEKI-OOPHOKITIS — ABSCESS OF OVARY. 89 
 
 lady is the child of parents of markedly nervous temperament, 
 is well-grown, I might almost say prematurely developed in 
 every way, and, when little over thirteen, began to menstruate. 
 From the beginning her periods were profuse, and at first pain- 
 less. She enjoyed excellent health for many months after the 
 accession of menstruation, during which time the flow continued 
 profuse, generally lasting for six days or a week, and necessita- 
 ting the use of from four to six napkins daily. By the time she 
 was fourteen it was, however, evident that her health was suf- 
 fering. She became listless, sleep}^, fainted when at her lessons, 
 gave indications of loss of memory, and, when I saw her first, 
 she was decidedly anaemic. At that time it wanted but two or 
 three days before the accession of her period, and steady pres- 
 sure over the ovaries gave her great pain. Avhich she described 
 as turning her quite sick. During menstruation this pain was 
 induced by less pressure, but in the intermenstrual period it 
 could not be produced at all. She always seemed better in 
 health during the flow, and it was this very common peculiarity 
 that prevented her parents from applying earlier for the much- 
 needed advice. 
 
 In such a case there cannot be a doubt that there is hyperse- 
 mia, not only of the ovary, but of the whole sexual apparatus, 
 due to, it may be, or more probably only accompanying, the 
 increased ovarian activity. This of itself is not a source of dan- 
 ger, for that lies in the menstrual loss producing anaemia. I 
 have not yet had an experience sufficiently extended to trace 
 such a case throughout its course ; but, meeting with many in- 
 stances which I have had reason to regard as identically of the 
 same nature in later stages, I believe that their menstrual his- 
 tory is much the same as that of other women after they have 
 had a child, the process of gestation seeming to rectify in great 
 measure the abnormal excitement. If they remain unmarried, 
 thej^ go on suffering from menorrhagia, become extremely anae- 
 mic, and have the menopause at the usual time, but marked 
 with abnormal prof usen ess, as might be expected. I have re- 
 peatedly had occasion to observe that marriage, even without 
 resulting pregnancies, often seems to do good in the way of 
 modifying the monthly hemorrhage. In other cases, however, 
 marriage seems to make them very much worse, to induce 
 chronic ovaritis, displacement of the ovaries, and finally to 
 destroy their health entirely. 
 
 The treatment of such cases should, if possible, be begun in 
 the first stage. There is no cause of deteriorated general health 
 so certain for a young woman as profuse menstruation due to 
 ovarian hyperaemia. The spanaemic condition induced by a few
 
 90 DISEASES OF THE OVARIES. 
 
 years' continuation of it is one over which iron seems to have no 
 control ; indeed, all ferruginous preparations ought to be sedu- 
 lously avoided until the nienorrhagia has completely ceased. 
 
 In the cases such as I have narrated, my first advice is that 
 the patient should be removed from school ; and that, for six 
 months, all instruction, especially in music, should cease. I 
 notice music especially, for I am quite certain that instruction 
 in that art, as carried out in boarding-schools, has to answer for 
 a great deal of menstrual mischief. To keep a young girl, dur- 
 ing her first efforts of sexual development, seated upright on a 
 music-stool, with her back unsupported, drumming vigorously 
 at a piano for several hours, can only be detrimental. It is usu- 
 ally the habit of those who superintend the education of girls to 
 make no difference whatever in their physical and mental exer- 
 cises during their menstrual periods ; and, at a time when the 
 great necessity of the system is perfect rest, laborious efforts 
 have to be made. This is most pernicious, and I have repeatedly 
 had to trace to it the existence of serious disease in j^oung ladies. 
 Musical exercises are especially hurtful, for the further reason 
 that music, in those who are devoted to it and gifted with its 
 necessary peculiarities, is a strong excitant of the emotions ; 
 •while to those not so gifted, and who do not care for it. musical 
 exercises are an intolerable and useless burden. Absolute rest 
 is an essential part of the treatment of the early stage of ovarian 
 hyper?emia, and I need scarcely say that it is in its early stage 
 that the treatment is most likely to be successful. This rest 
 ought to be rigorously carried out by the patient being confined 
 to the prone position for a few days before, during, and for a 
 few days after, the catamenial flow. The application of a coun- 
 ter-irritant over the ovarian region, just before the period, is 
 ver}' useful ; but the most potent part of the treatment consists 
 in the administration of ergot before and during the period, and 
 of the salts of potassium continuously during the intermenstrual 
 time. The ergot is best given in the form of ergotin, my favorite 
 formula being half a grain of Bonjean's ergotin made into a pill 
 with suflflcient lupulin. The bromide I give night and morning, 
 after meals, in doses from five to ten grains. There is a great 
 deal to be done in moral treatment. It may be only a coinci- 
 dence, but I have noticed this affection chiefly in -girls who have 
 had no brothers, or brothers only younger than themselves ; and 
 I am quite certain that great harm is done to many girls by their 
 rigid social seclusion, in youth, from the companionship of boys. 
 Under proper supervision, no wrong could happen from more 
 unrestricted association of boys and girls at theirtritical periods: 
 and it seems to me that it is a mischievous plan to draw wide
 
 OOPIIOKITIS AND PERI-OOPHORITIS — ABSCESS OF OVARY. 91 
 
 barrier-lines between the sexes at a time when they ought to 
 begin to understand themselves and each other ; and, by harm- 
 less intercourse, many of the risks may be obviated which after- 
 ward beset them when an unaccustomed association is opened 
 out at an age when instinct has the chief ascendancy. 
 
 While upon this subject, I should neglect my duty were I to 
 refrain from speaking on another subject concerning the educa- 
 tion of girls. There has grown up a desire to educate women in 
 exactly the same way and to the same extent as men. It would 
 be easy for me to show, were any charge of obstructiveness or 
 want of liberality to be made against me. that throughout my 
 public life I have ever been in the front rank of those who advo- 
 cate perfect freedom of every kind of instruction for every one 
 who may desire it ; and I have been particularly strong in the 
 expression of my views that there should be restriction of neither 
 class nor sex. But it is useless to disguise the fact that, inas- 
 much as women have functions to fulfil which men are free 
 from, it is not to •be expected that women can, with safety, do 
 the work of men, and at the same time properly fulfil their own 
 special functions as women. The questions raised by the ad- 
 vanced advocates of women's rights are to be settled, not on the 
 platform of the political economist, but in the consulting-room 
 of the gynecologist. This is no place to air political crotchets, 
 but I may own myself an advanced advocate of women's rights ; 
 at the same time I cannot help seeing the mischief women will 
 do to themselves, and to the race generally, if they avail them- 
 selves too fully of these rights when conceded. It may be, and 
 probably is. a very gratifying circumstance for a young woman 
 to go to a college, and show that she could take as high a de- 
 gree as a man ; but, considering the fact that she has a monthly 
 disturbance, she would take this degree at a price which a man 
 would not have to pay for it. To fulfil the necessary conditions 
 she will tax herself to such an extent as will, in all probability, 
 make her functions imperfect. To continue the career begun 
 at college, she must deny herself the congenial occupations of a 
 wife and the pleasures of maternity, and thus she robs the hu- 
 man race of what it wants most, brain-power on the part of the 
 mother. To leave only the inferior women to perpetuate the 
 species will do more to deteriorate the human race than all the 
 individual victories at Girton will do to benefit it. This over- 
 training of young women is wholly unnecessary in the interests 
 of human progress, and it is mischievous alike to themselves 
 and to humanity. To hear an elderly maiden lady read a learned 
 paper on mathematics may be a gratifying circumstance, but 
 it is largely qualified by regrets when we speculate what supe-
 
 92 DISEASES OF THE OVARIES. 
 
 rior children she might have produced if she had been a little 
 less learned in books. Those who advocate the equal treatment 
 of the sexes must bear in mind that great culture in a man does 
 not unfit him for paternity, but, on the contrary, will help him, 
 in the struggle for existence, to maintain a family. For women, 
 on the contrary, exceptional culture will have infallibly the 
 tendency to remove the fittest individuals, those most likely to 
 add to the production of children of high class brain-power, 
 from out of the rank of motherhood. 
 
 All the cases of ovarian hypersemia which I have met with 
 at puberty have yielded to the treatment I have detailed, and 
 many cases which I have had reason to regard as of this nature, 
 but in a later stage, have been benefited by it. It is, however, 
 in the perfect fulfilment of the function of the utero-ovarian or- 
 gans that we have the radical cure. 
 
 Ovarian hypersemia is sometimes met with as the result of 
 marriage, especially when the marital acts have been indulged 
 in to excess, and particularly when pregnancy has not resulted. 
 This, in fact, is only the mildest form of a serious disease which 
 may end in total inflammatory disorganization of the ovaries of 
 newly married women. It is not unusual to find a delicate wo- 
 man, who had menstruated normally previous to her marriage, 
 suffer from severe menorrhagia for the first three or four years 
 of married life, and to find an explanation of this in the vigor of 
 the husband. In these cases ovarian tenderness is always pres- 
 ent, and very frequently there is violent pain and tenesmus, 
 lasting for hours after connection, so that soon the unfortunate 
 sufferer dreads the idea of a marital embrace. The menstrual 
 period becomes prolonged, so that there is left only an intermen- 
 strual interval of a few days. In prostitutes of a tender age this 
 affection is of extreme frequency, and often ends in the chronic 
 ovaritis with adhesion of the Fallopian fimbriae to the ovary, 
 and the subsequent atrophy of all the sexual structures so often 
 found in their bodies. The recurrent inflammatory attacks thus 
 induced in these unfortunates have been termed colica scorto- 
 rnm. The cure depends, of course, on the removal of the excit- 
 ing cause and the employment of such treatment as has been 
 before alluded to, but in severe and protracted cases it will be 
 effected only by removal of the ovaries and tubes. This step is 
 to be resorted to only after the failure of everything else, but 
 many times I have been obliged to adopt it, and always with 
 the best results. The idea that removal of the ovaries will un- 
 sex a woman is founded on ignorance. So far as maternity is 
 concerned, it of course destroys the function completely ; but 
 that has already been done by the disease for which the opera-
 
 OOPHORITIS AND PERT-OOPHORITIS — ABSCESS OF OVARY. 93 
 
 tion has been performed. A woman who has suffered for years 
 from chronic ovaritis with adherent tubes, and possibly hydro- 
 salpinx or pyo-salpinx, is necessarily barren, so that to remove 
 the uterine appendages is to make her no worse than she was. 
 But such a disease as this will oblige her to suspend marital re- 
 lations, or to endure them only as a matter of duty, and with 
 great suffering. To remove the diseased structures will be to 
 enable her satisfactorily to perform her marital duties, and the 
 operation, if successful, will be found really to reinstate her in 
 her sexual functions, and not to unsex her. 
 
 In very many of the cases of which I now speak, no line can 
 be drawn which will define where simple hypersemia ends and 
 acute or chronic ovaritis begins. In many of them we get a 
 distinct history of an acute attack, which was probably ovari- 
 tis, while in others the symptoms came on gradually, without 
 any noticeable starting-point, and ovarian hypersemia probably 
 in these passes insensibly into chronic ovaritis. I propose here 
 to give a series of cases illustrating these different classes. 
 
 E. S was a young married lady, whom I first saw in May, 
 
 1879, with Mr. Arthur Newton, of Newhall Street. Her men- 
 struation commenced when she was thirteen years of age, was 
 always so painful that she was confined to bed while it lasted, 
 being wholly unable to get about or sit up. This pain came on 
 invariably two days before the period lasted, so that she began 
 her sexual life with diseased ovaries. She was married in 187G, 
 and marriage made her very much worse. She became pregnant 
 in three months, and it was hoped that this would cure her, but 
 it did not. After her confinement she had an acute attack of 
 pelvic peritonitis, which seems to have been a very serious ill- 
 ness. She became pregnant again, and was confined in January, 
 1879, and had another inflammatory attack, and from that time 
 she was never out of bed till after the recovery from the ovari- 
 otomy which I performed on her on February 9, 1880, 
 
 I saw her, as I have said, first in May, 1879, and I then found 
 the fundus very large and retroverted, with the ovaries also 
 much enlarged, extremely tender, and lying down below the 
 fundus. She could bear no kind of pessary; the menstruation 
 was regular and profuse, and the pain during its continuance 
 amounted to agony. I advised blistering, morphia, pessaries, 
 and the abundant administration of bromide of potassium and 
 ergot. This treatment had no effect, nor had the efforts of an- 
 other specialist under whose care she was afterward placed. I 
 saw her again, with Mr. Newton, in January, 1880, and found 
 her condition much worse. She had all the old symptoms, but
 
 94 DISEASES OF THE OVARIES. 
 
 in addition she was feverish, worn, and hectic. Everything had 
 been tried and had failed, and ovariotomy only remained. To 
 this Mr. Newton agreed, and so did the patient, her husband, 
 and friends. I found both ovaries adherent in the cul-de-sac, 
 and much care had to be exercised in detaching them. They 
 were very soft, greatly enlarged, and covered with lymph. She 
 made an uninterrupted recovery, and got up on March 5th. On 
 April 1st she walked about the house for the first time in 
 eighteen months, and had gained greatly in every respect. On 
 July 20th she was able to walk a mile, and had got quite stout, 
 was entirely free from pain, marital relations had been resumed 
 with perfect satisfaction, and this, as she frankly told me, for the 
 first time in her life. On September 9th I saw her get down 
 without assistance from a high dog-cart, and run briskly up 
 some steps, as if she had never ailed. She has not had the 
 slightest appearance of menstruation since the operation, and 
 the climacteric disturbance is quite over (February, 1881), and 
 she is in perfect health. 
 
 The patient, her friends, her attendant Mr. Newton, are all 
 quite as well satisfied as I am with the result of this case, and 
 that nothing short of ovariotomy would have saved her life. 
 The only thing I regret is that I did not operate many months 
 earlier than I did. In this case the patient probably suffered 
 from ovarian hypersemia during the whole of her menstrual life, 
 and this was transformed into chronic ovaritis by an acute at- 
 tack in the puerperal state. 
 
 On February 20. 1880, a lady was brought to me from London, 
 who had been confined to the recumbent position for seven years, 
 and to bed absolutely for nearly four years. Her menstruation 
 began at twelve years of age, was not very regular, and was 
 always accompanied by pain. It continued much the same till 
 she was about twenty-eight years of age, when she had an ill- 
 ness, and, ever since, the pain during menstruation has been 
 much more severe, and had become progressively so for the last 
 nine years. During the four years she had been under the care 
 of Dr. Graily Hewitt, and had undergone prolonged, careful, 
 and various treatments by pessaries, etc. , but without the slight- 
 est benefit ; in fact, she got continuously worse. When I first 
 saw her, the history was given that menstruation was perfectly 
 regular, lasting from six to eight days, and was very profuse. 
 Just before the period severe pain came on, and lasted, with 
 slight intermission, the whole time. The pain in her back was 
 incessant, and utterly prevented her walking. I found the ute-
 
 I 
 
 OOPJIOlllTIS AND PEKI-00PH0K1TI8 — ABSCESS OF OVAEY. 9o 
 
 rus quite bent upon itself backward, and so retroverted as to be 
 almost turned upside down. The fundus was very large and 
 soft, and the ovaries, much enlarged, were alongside and below 
 it. The organs were so excessively tender that without ether 
 examination was impossible, so that I am not surprised no pes- 
 sary could be endured. 
 
 I explained to the lady and her friends that the conditions 
 were such that no effort at rectification by pessary need be at- 
 tempted ; that, if Dr. Hewitt had failed, I was not likely to suc- 
 ceed ; and that the radical cure of ovariotomy was the only one 
 which promised success. This they accepted, and I performed 
 the operation on the 2Gth. The ovaries were enormously en- 
 larged, but not cystic ; the fundus was soft and spongy, and 
 nearly three times the size it ought to be in a virgin. There 
 were no adhesions. After removing the ovaries, and whilst 
 closing the wound, I passed a stitch through the fundus, and 
 fastened it up to the abdominal wall. She recovered per- 
 fectly, has never menstruated since, is getting fat and well, 
 and can now walk about the house and garden. The re- 
 covery of her power of locomotion is slow, but steady, and I 
 need hardly say that, after seven years of their suspension, we 
 can hardly expect any very rapid progress. The uterus is now 
 perfectly straight and normally hung, and it is quite of the 
 senile size. 
 
 The next case was that of a lady, aged thirty-three, who be- 
 gan to menstruate at thirteen, was married at twenty, and in 
 eleven years had seven children. Her first child was born prema- 
 turely, and she had never been well since, for she got up and un- 
 dertook a railway journey on the fourteenth day. After this she 
 had continuous hemorrhage for several months. She had sev- 
 eral premature and dead children after this, and then one living 
 child, and the seventh dead. Three years previous to my seeing 
 her she consulted a distinguished metropolitan specialist, who, 
 upon his consulting-room couch, "did something to her which 
 gave her immediately a violent pain in the back," and that pain 
 she never lost for an hour, save when asleep or narcotized, till 
 the day I operated upon her. What this was which was done to 
 her, of course I do not know, though I have little doubt it was the 
 rectification of her remarkable retroversion by the sound. If it 
 was, it is another example which we may quote against this 
 mischievous practice. When I first saw her I got the story that 
 ever since this incident the patient's life was a misery to her and 
 her surroundings — that she could not get about — was on the 
 couch all day long — her menstruation so protracted and profuse 
 that it lasted quite half the month — and she had hardly recov-
 
 9G DISEASES OF THE OVARIES. 
 
 ered from, the exhaustion consequent upon the loss and the in- 
 crease of her sufferings when she was ill again. She had been 
 under the hands of quite a number of specialists both here and 
 in London ; and after reading up her case, and comparing the 
 opinions expressed about it, and having come across one of my 
 cases of spaying, she came to me deliberately, to ask me if I 
 thought I could spay her, and, if I could, if I thought it would 
 do her good. She had been told that the womb was bent back- 
 ward, but that tliere was a tumor on either side of it. The tu- 
 mors in question I found to be enormously enlarged and very 
 tender ovaries lying behind and below a retroflected and retro- 
 verted fundus, which felt so large that it really might have been 
 a question whether or not there was a myoma in it. From my 
 previous experience, I was of opinion that fundal enlargement 
 was due merely to chronic fundal metritis, though I was quite 
 prepared to find a myoma at the operation. 
 
 I had no difficulty, in such a case as this, in recommending 
 the removal of the ovaries, for the mere names of the gentlemen 
 under whose care she had previously been, without benefit, were 
 sufficient guarantee that everything short of that had been tried. 
 Moreover, the patient, a clever, intelligent woman, knew all 
 about her case, and told me pretty accurately all that had been 
 done. I had. besides, the advantage of the history given by one 
 of her medical attendants. 
 
 The immediate arrest of the hemorrhage, which had been un- 
 controlled even by hypodermic injection of ergotin, would alone 
 have been a sufficient warrant for the ovariotomy, but there 
 were numerous other reasons in its favor. I therefore performed 
 it on April 9th, and found the fundus enlarged from chronic fun- 
 dal metritis only, the ovaries enlarged from chronic interstitial 
 inflammation, and the displacement as I have described it. I 
 removed the ovaries and stitched the uterus up to the wound as 
 in the previous case. She made an uninterrupted recovery, and 
 has never menstruated since. She is now full of color, stout, 
 and well in every respect but one. She went through the early 
 stage of the climacteria without much suffering, and these dis- 
 agreeables are passing off rapidly. For six weeks after the oper- 
 ation she was absolutely free from the terrible pain in the back ; 
 but as she began to get about it came back, and for a time was 
 as bad as ever, despite the uterus being absolutely normal in 
 position and speedily regaining its normal size. This pain in 
 the back still continues in a modified form, and is, I believe, 
 slowly fading away ; and I have not the least doubt it will en- 
 tirely disappear in time. Why it has returned, and why it has- 
 lingered so long, I do not know, for there is no physical reason
 
 OOPIIOKITIS AND PEEI-OOPHORITIS — ABSCESS OF OVARY. 97 
 
 for it perceptible. In every other respect the results of the oper- 
 ation fully justify its performance. 
 
 In very many cases such as these, there will be found no inci- 
 dent in the history from which it can be said that ovarian hyper- 
 semia was transformed into chronic ovaritis. In others a distinct 
 history can be given of an acute attack, from which the chronic 
 suffering can be dated ; and my belief is that the two classes 
 may be more carefully defined by further observation, and that 
 their pathological features are wholly different. 
 
 So far as I know, acute ovaritis is the result of four condi- 
 tions only : 
 
 1. Injury ; 
 
 2. Gonorrhoeal infection ; 
 
 3. Septic poisoning in the parturient condition ; 
 
 4. Exanthematic fevers and acute rheumatism. 
 
 In one woman I diagnosed acute ovaritis following injuries 
 inflicted by her paramour kicking her ; and though it may have 
 been general pelvic peritonitis, yet the uterus never became 
 fixed as it does in that condition, and the subsequent permanent 
 disturbance of menstruation, accompanied by other signs of 
 chronic ovaritis, confirmed me in my opinion. 
 
 Acute ovaritis from gonorrhoea is a common result of the in- 
 fection, and is a frequent cause of sterility. It seems to be pre- 
 cisely similar to the acute epididymitis of the male, as was first 
 pointed out by Bernutz and Victor de Meric. In this affection 
 the patient is found with an anxious face, agonizing pelvic pain, 
 generally only on one side, the knees drawn up, aigd all the 
 signs of a severe inflammatory attack. The patient can lie with 
 comfort only on the back, and micturition and defecation are 
 productive sometimes of excruciating pain. It is often impossi- 
 ble to make a vaginal examination without an ansesthetic, and 
 this had better be used at once, for it is a matter of consequence 
 to diagnose between acute ovaritis and pelvic cellulitis. In the 
 latter the tumor will be found attached to the uterus, and mov- 
 ing with it and with the whole roof of the pelvis, and will be 
 found to be more or less fixed ; while in ovaritis the enlarged 
 ovary may, as a rule, easily be made out. The treatment should 
 consist in leeches to the perineum, a blister over the ovary, diu- 
 retics, and small, frequent doses of opium. The rectum should 
 be well evacuated by an enema, and the bowels kept quiet for a 
 few days. The great risk of the disease is that of its spreading 
 into general peritonitis. In the event of the attack appearing to 
 threaten the life of any patient under my care, I would not hesi- 
 tate to open the abdomen, cleanse out the cavity, and possibly 
 7
 
 98 DISEASES OF THE OVARIES. 
 
 remove the diseased organs. When an ovarian tumor is gan- 
 grenous or suppurating, we serve the patient by promptly re- 
 moving it, and I do not see why this principle should not be ex- 
 tended. The result of the disease is nearly always to destroy 
 the functions of the glands, and therefore, in prospect of a fatal 
 issue of the disease, the argument against an operation, that it 
 will unsex the patient, need not be considered. 
 
 Gonorrhoeal ovaritis is an extremely treacherous disease, or 
 rather, perhaps I ought to say that gonorrhoea is a disease which 
 in women may be fraught with the most serious and unexpected 
 consequences. Some years ago a gentleman who had been a 
 short time married, visited a neighborhood where he unfortu- 
 nately met a friend of his bachelor days. Within forty-eight 
 hours he came to me in terrible distress, with the initial symp- 
 toms of gonorrhoea, but Avith the still more terrible dread that 
 he might have conveyed it to his wife, for intercourse had taken 
 place a few hours before his symptoms appeared. Of course I 
 at once cautioned him to refrain absolutely from intercourse 
 with his wife — advice which I have no reason to believe that he 
 disregarded. His gonorrhoea proved very trifling, and passed 
 off entirely in less than a week. Wishing to take his annual 
 holiday, he brought his wife to me to make sure that she was 
 free from disease, and I could not find the slightest trace of va- 
 ginitis. I therefore sanctioned their travelling to a considerable 
 distance. But within three days I was summoned to her, and 
 found her suffering from a most severe attack of inflammation 
 of the left ovary. After some weeks she got well, though the 
 ovary could be felt, both by rectum and vagina, as large as 
 a small orange, firmly fixed and exquisitely tender. Suddenly 
 the right ovary became similarly affected ; and after a most se- 
 vere illness, during which she seemed frequently at the point of 
 death, she recovered, with the right ovary similarly enlarged 
 and fixed. She never menstruated after this second illness, and 
 she now lives a semi-invalid life, hardly ever free from pain, 
 and unfit for any great exertion, though as time goes on her suf- 
 ferings seem to obtain slight amelioration. She is quite unable 
 to endure marital intercourse, and the best thing that could be 
 done for her would be removal of the uterine appendages. She 
 belongs, however, to the better ranks of life, and we find that 
 patients of this class very often prefer a chronic invalidism to 
 the risks of an operation. They can pay for any amount of lux- 
 ury and medical attendance, and they do what is best for their 
 doctors in a pecuniary sense, but not what is best for themselves. 
 
 The history of such a case is undoubtedly that the poison has 
 permeated the uterus and Fallopian tubes, alighting' on the ovary
 
 OOPHORITIS AND PEKI-OOPHORITIS — ABSCESS OF OVARY. 99 
 
 from the tube probably at the time that the fimbriae were in as- 
 sociation with it ; but it is somewhat surprising that there was 
 never any trace of vaginitis. 
 
 A case of alternating ovaritis, for which I have been unable 
 to discover any cause, has been for some time under my care in 
 
 hospital practice. The patient, J. K , aged twenty-five, came 
 
 to the hospital with well-marked acute inflammation of the left 
 ovary. She had been married for three years, and had never 
 been pregnant. There was nothing in her history to make me 
 suspect that she had suffered from gonorrhoea, nor did she know 
 of her husband having so suffered. The left ovary recovered in 
 a few weeks, but remained somewhat enlarged and very tender, 
 and it was also somewhat fixed. In about two months she came 
 back with the right ovary quite as severely involved, and has 
 since been several times under care with recurrences on one or 
 other side ; but both ovaries have never been attacked together, 
 and none of the attacks have been associated with menstruation, 
 which, always irregular, has been gradually getting rarer and 
 more scant. The most probable explanation of this curious case 
 is, that she is exposed every now and then to some infection 
 which travels up her Fallopian tubes, and attacks the ovaries 
 without giving any indication elsewhere of its presence. The 
 possibility of such an event must always be borne in mind, and 
 as a guide to future directions it may be advisable to ask cau- 
 tiously into the history of an attack of acute ovaritis. Whatever 
 "be the explanation, it must ever be borne in mind that ovaritis 
 is a disease peculiarly liable to relapses, and cautions upon this 
 jioint must be given to the patient. 
 
 Of acute ovaritis in childbed from septic causes, as distin- 
 guished from general septic peritonitis in which the ovary is 
 involved, my experience is limited to one case in which, hke 
 those recorded by Simpson, Bernutz, and others, an abscess re- 
 sulted. The infection occurred after a miscarriage in tJie wife 
 of a medical man, and was distinctly limited to the two ovaries, 
 as was readily determined by an examination under an anses- 
 thetic. An abscess formed in the right ovary, and I tapped it in 
 the early stage by means of the aspirator, with a completely 
 successful result. The general symptoms were pain, elevation 
 of the temperature, night-sweats, drawing up of the knees, infra- 
 mammary pain, and pain shooting down the thighs and legs. 
 The chief remedies employed were counter-irritants, such as 
 turpentine stupes and blisters, and the internal administration 
 of quinine and opium. The aspiration was, of course, performed 
 through the vagina. 
 
 Of this disease. Dr. Mathews Duncan describes a case in
 
 100 DISEASES OF THE OVAllIES. 
 
 which "the right ovary was swollen, renitent, as big as a wal- 
 nut, and when cut into was found to have its healthy tissue 
 every w^here utterly destroyed, and converted into a yellow, puru- 
 lent, almost diffluent mass. There was no lymph in Douglas' 
 space. Bladder and uterus normal ; no general peritonitis. Of 
 such ovaritis, with suppuration, examples are not rare, because 
 puerperal pysemia is not rare." 
 
 It has long been known that, in certain zymotic diseases, 
 especially in mumps and scarlet fever, male children are apt to 
 suffer from orchitis, and I remember seeing a statement some- 
 where that such inflammation of the testicle was likely to be fol- 
 lowed by atrophy and loss of its function. I cannot, however, 
 verify my recollection by producing the reference. 
 
 In 1870 and 1871, and still more in 1874, my attention was 
 drawn to the occurrence of acute pelvic peritonitis in women 
 after attacks of scarlet fever and small-pox, these attacks leav- 
 ing indications wdiich showed clearly that the miscliief began in 
 the ovaries. Accident enabled me to trace the subsequent his- 
 tory of two such cases, and I found that in both the menstruation 
 became greatly diminished in amount, that it was accompanied 
 by severe dysmenorrhoeal symptoms, and that in one of the cases 
 it entirely disappeared. From these cases I began to suspect 
 that the attacks were primarily due to inflammation of the 
 uterine appendages, and that this had some kind of relation to 
 the zymotic diseases which preceded it. 
 
 The terrible outbreak of small-pox from which this town suf- 
 fered between 1872 and 1874 gave me the opportunity of follow- 
 ing out this line of research, and in the second edition of my 
 Hastings Essay on the *' Pathology and Treatment of Diseases 
 of the Ovary'' I sum up my conclusions upon this subject, and, 
 up to the present time, I have seen no i-eason to modify' them : 
 
 " The occurrence of acute ovaritis in certain of the exanthe- 
 mata, or as a sequela to them, has never yet, so far as I know, 
 been placed in sufficient prominence. I have already alluded to 
 it, but I wish here to record further experience gained from an 
 epidemic of small-pox of considerable severity, which existed in 
 Birmingham from 1873 to 1874. Though practising exclusively 
 as a gynecologist, it is somewhat curious that I was called in 
 consultation to four cases as instances of pelvic ailment which 
 ultimately proved to be cases of small-pox. One of,1;hese gave 
 the clinical features of the exanthematic ovaritis with great 
 clearness. She had been married four years, and had been con- 
 fined twice. She was pregnant for the third time in September, 
 1873, when she was seized with a sudden rigor, followed by se- 
 vere pyrexial symptoms. These rapidly became localized in the
 
 OOPHORITIS AND PERI-OOPHOKITIS — ABSCESS OF OVARY. 101 
 
 pelvis, the patient complaining of excruciating pain in each iliac 
 fossa. I saw her on the fourth day of her illness, and found her 
 suffering from double acute ovaritis and threatening abortion. 
 She aborted on the fifth day, and then showed a papular erup- 
 tion of small-pox, which rapidly became confluent. She made a 
 very protracted recovery, and has never menstruated since. 
 The fundus uteri is fixed down on the sacrum, and both ovaries 
 are enlarged and tender, the left being firmly fixed alongside 
 the uterus. 
 
 "' In hospital practice I met with a large number of cases, of 
 which the following is a good example : H. A , aged twenty- 
 two, began to menstruate a short time after she was fourteen, 
 and was quite regular till August, 1872. At that time she had 
 an attack of small-pox, which she says was not severe, and which 
 has not left any deep marks. Up till the time of that illness she 
 was strong and robust, and never knew what illness was. Dur- 
 ing the attack she had a very profuse menstruation at an irregu- 
 lar time, and this was followed by severe abdominal pain, which 
 was treated by hot fomentations. She did not get rid of this 
 pain entirely for some months, and since then she has menstru- 
 ated at long intervals, the discharge being very scant, and ac- 
 companied with great pain. She is now very anaemic, though 
 still stout, is short of breath, and lias a loud systolic ha^mic mur- 
 mur at the base. The ovaries are not to be felt at all, and there- 
 fore it is probable that they have become atrophied. She ob- 
 tained considerable relief from small doses of iron, combined 
 with chlorate of potash. I have no doubt that she had an attack 
 of acute exanthematic ovaritis, which has led to atrophy of the 
 organs. 
 
 ''I have repeatedly seen, on post-mortem examination, cir- 
 rhotic atrophy of the ovaries in women who had by no means 
 reached the usual climacteric period of life, but had prematurely 
 ceased to menstruate. In one case only could I get a history of 
 the menstrual life of a patient, which was to the effect that she 
 had not begun to menstruate till twenty years of age, and had 
 ceased before she was thirty ; and about that time she had an 
 illness which probably was scarlet fever. The ovaries were small 
 and shrivelled, and a stained section showed that nucleated and 
 banded fibres constituted the bulk of the glands. Here and there, 
 in small loculi whence the bands seemed to radiate, a small group 
 of cells served to indicate the site of a Graafian follicle, but no 
 perfect follicles could be found. This extreme instance was the 
 result probably of two factors — insufficient development and ex- 
 antheinatic atrophy. I think that in such cases it is likely that 
 future observation will establish the existence of an intersti-
 
 102 DISEASES OF THE OVARIES. 
 
 tial oophoritis, distinct in character and perhaps in origin from 
 the ordinary acute inflammation of the peritoneal covering of 
 the ovary, to which latter we might more appropriately give the 
 name of peri-oophoritis. The results in the two classes seem 
 to be different ; for in the second, menstruation does not seem to 
 be suppressed, but, on the contrary, it is sometimes excessive ; 
 while, as a result of the supposed interstitial form, we have ova- 
 rian atrophy and amenorrhoea of an incurable form ; and when 
 it occurs in puerperal women, superinvolution of the uterus." 
 
 The views which I have expressed in these sentences have 
 now been fully confirmed by my own experience and further in- 
 vestigations, and I have no doubt now that there is a special 
 form of oophoritis associated with certain exanthemata, more 
 particularly scarlet fever and small-pox, and that in its results 
 it differs altogether from the form of ovarian inflammation to 
 which I prefer to give the name of peri-oophoritis. 
 
 The most important result of this specific form of ovarian in- 
 flammation is that it leads to a cirrhosis of the ovary which may 
 or may not be characterized by general atrophy. It always is 
 indicated, as I have said, by atrophy of the true gland-structure 
 and excess of the fibrous element. How this may be brought 
 about is not yet clear ; but, as I shall show you immediately, 
 the facts are fully established, and my own explanation is that 
 it is due to the absorption of the gland-elements after the inflam- 
 mation, while the fibrous elements are left, just as is said to oc- 
 cur in the contracted kidney and in other instances of cirrhosis. ' 
 
 Whatever be the process, there is no doubt that it is some- 
 times associated with atrophy of the uterus, resulting in what is 
 known, and w^as first described by Simpson, as superinvolution 
 of the uterus. At page 119 of my book on "Diseases of Women,"' 
 I hazard the following explanation of this condition : 
 
 " Of superinvolution of the uterus, it must first be said that 
 it is an extremely rare affection, and that all we know about it 
 is due to Simpson. It is a condition perfectly analogous in its 
 details to arrest of development of the uterus, with the differ- 
 ence in history that the superinvolved uterus has at one time 
 been so large as to be pregnant. How the normal involution is 
 
 ' Dr. Saundby, Pathologist to the Hospital for Women, who has given much care 
 and personal work to this subject, tells me that it is still a rjuestio rexatn of pathology 
 how far the connective tissue of cirrhosed organs is derived from retrogressive trans- 
 formation of the pre-existent more highly organized elements, e.g., glandular epithe- 
 lium, etc., into spindle-cells and fibres, and how much is due to cell-migration from 
 the blood- vessels and proliferation of the connective-tissue corpuscles. It is probable 
 that the first of these processes plays a more important part than has been assigned to- 
 it in the doctrines which have found most favor during the past few years.
 
 OOPHOKITIS AND PERI-OOPHORITIS — ABSCESS OF OVARY. 103 
 
 carried on to hypererchesis we do not know ; and, so far as I can 
 discover, we have only one description of the post-mortem ap- 
 pearance of a uterus so affected — that given originally by Simp- 
 son. The patient was twenty years of age, and had never men- 
 struated after her first delivery ; but no history is given of any 
 febrile illness to which might have been attributed the abnormal 
 absorption of the uterine substance. After death the uterus was 
 only an inch and a half long, and its walls were less than half 
 their normal thickness, their tissue appearing dense and fibrous. 
 The ovaries were also much atrophied, and their dense fibrous 
 tissue presented no appearance of Graafian vesicles. In this 
 case it is, of course, doubtful whether the process was truly one 
 of ovarian atrophy, followed by atrophy of the uterus, in obedi- 
 ence to the usual law that all useless organs tend to disappear. 
 Several cases of what I have had reason to believe was true su- 
 perinvolution of the uterus have come under my care, but in 
 every one there ha,s been some febrile illness, generally of a 
 zymotic character, which occurred at, or soon after, a labor or 
 miscarriage : and my impression is that, of all the cases, those 
 in which a miscarriage was the origin of the trouble were in the 
 majority. In fact, I am strongly disposed to regard superinvolu- 
 tion as a result of an atrophic inflammation occurring at the time 
 when involution is going on. Thus, in a case which I published 
 in the London Obstetrical Journal for May, 1873, and which cer- 
 tainly was the most pronounced case of superinvolution I have 
 ever seen, the patient had had scarlet fever during the first week 
 of her convalescence from her second labor. She came under 
 my care in 1871, seven years after the fever, and has remained 
 under observation ever since. When I first saw her the uterus 
 was perfectly infantile, the vaginal portion of the cervix being 
 represented only by a pimple. Her menstrual periods had dis- 
 appeared, and were replaced by severe epileptiform seizures, as 
 will be found detailed in the journal. I succeeded in getting 
 menstruation restored, and the uterus increased in size by the 
 use of galvanic pessaries, and as her periods became re-estab- 
 lished the epilepsy disappeared. But when I discontinued the 
 use of the pessary the menstruation slowly disappeared and the 
 fits came gradually back, and this therapeutical experiment has 
 been several times repeated with uniform results ; and that the 
 fits are epileptic is made certain by the severe injuries the poor 
 woman inflicts upon herself during the attacks. Looking back 
 on this case and others, and aided by the evidence of other facts 
 referred to under the head of exanthematic ovaritis, I am led to 
 believe that superinvolution is explained by the occurrence of in- 
 flammation, followed by atrophy, during the puerperal month ;
 
 104 DISEASES OF THE OVARIES. 
 
 and that the uterus merely follows in the steps of the ovary, car- 
 rying the process farther, however, because it had been already 
 in action, and stopping it only when, perhaps, there was no more 
 muscular tissue left to absorb. ' I do not suppose that the excit- 
 ing ovaritis need necessarily be exanthematic, but peri-oophoritis, 
 or inflammatory action affecting only the covering of the ovary, 
 does not seem to affect menstruation; it rather inclines to induce 
 sterility only. These views would explain many facts which are 
 otherwise irreconcilable, and, what is most of all remarkable, 
 the rarity of superinvolution. First of all, exanthematic or other 
 interstitial ovaritis, such as leads to ovarian atrophy and is not 
 fatal, is very rare in puerperal women, the great majority of 
 such cases ending in death. The few who recover are likely to 
 suffer from superinvolution. Again, numbers of non-puerperal 
 women who suffer from ovarian atrophy, the result of inflam- 
 mation, do not at the same time have atrophy of the uterus, 
 because when the ovarian process began the uterus was not al- 
 ready undergoing involution. This explanation is quite in ac- 
 cordance with the history of, and the appearances in, Simpson's 
 case, and also in harmony with the general principles of uterine 
 physiology. Its practical bearing is, that though in such cases 
 we may get temporary relief from the galvanic stem, that relief 
 will cease with the use of the instrument, or when, as sometimes 
 happens, its stimulus becomes insufficient," 
 
 The case now referred to is one of so much importance that, 
 at the risk of being tedious, I shall give its history fully from my 
 first acquaintance with the patient. The former part of the case 
 I take from the Obstetrical Journal of May, 1873, 
 
 " E, E , aged thirty-five, came under my care in November, 
 
 1871, at the hospital. She had been married twelve years, and 
 had two children, the last of which was born seven years ago. 
 She had scarlet fever after this labor, and the menses were long 
 in reappearing. When they did come they were scanty and very 
 painful, and occurred irregularly at intervals of from five weeks 
 to three months, lasting only one day, or two at most. About 
 four years previous to her first visit, slight attacks of an epilepti- 
 form nature occurred at each period — almost imperceptible at 
 first, but getting gradually worse as the periods got more irregu- 
 
 ' It is not to be supposed for a moment, however, that the uterus ever can be so 
 absorbed as to disappear altogether, even though it may be so thin that a sound can 
 be passed through it, as in the case recorded in the British Medical Journal for 1872, 
 p. 408, by Mr. Whitehead, of Manchester. At p. 465 of the same volume I offered the 
 moie feasible explanation that there had been formed a metro-peritoneal fistula.
 
 OOPHORITIS AND PERI-OOPIIORITIS — ABSCESS OF OVARY. 105 
 
 lar and scantier. For some months previous to applying at the 
 hospital she had two or three severe fits at each period, each fit 
 leaving her insensible for some hours, and often with severe in- 
 juries. On November 5th she had had a period and a very severe 
 fit ; 9th, ordered five-grain doses of the bromide of potassium 
 thrice daily, and an aloes and iron pill twice a week. Examined 
 on the IGth, and the uterus found quite infantile ; ovaries normal. 
 The uterus was so small that I failed to get anything into its 
 cavity. On the oOth I doubled the dose of the bromide. Decem- 
 ber 7th, menstruated for one day, and had increased flux and no 
 fit. Menstruated January 4th and 5th, with slightly increased 
 amount, and one severe fit on second day. Had a severe fit on 
 22d, without any menstrual flow — the first time this has hap- 
 pened. Menstruated February 1st and 2d ; no fit. March 11th 
 and 12th, menstruation without fit, but a severe seizure occurred 
 almost immediately after the flux ceased. On the 18th Mr. Jor- 
 dan kindly put her under chloroform for me, and I got a small 
 tangle-tent into the uterus. I at the same time discovered that 
 there was considerable anteflexion. March 25th, passed in No. 8 
 tangle-tent, and on the 29th I got No. 8 galvanic stem in. April 
 5th, got in No. 12 stem ; 7th, 8th, and 9th, menstruated more pro- 
 fusely than she has done for years, and without a fit, though 
 one occurred on the 16th. She still wears the stem, and men- 
 struates regularly and profusely, but has no fits." 
 
 From this point I continue the case from the hospital record. 
 
 On April 26th, 1873, I introduced No. 16 galvanic stem, the 
 largest I have ever used, and from May 3d to 7th she had a pe- 
 riod more profuse than she had ever had since her confinement. 
 On June 4tli she again menstruated for four days, again in July, 
 and also in August and September, during which time she wore 
 the large stem, and had not a single fit. 
 
 The stem was removed at the end of September, having been 
 worn five months with most satisfactory results. In November 
 she menstruated for one day only, and in December there was 
 no appearance of it at all, but a fit occurred at the time it was 
 expected. During the whole of this time she was taking sixty 
 grains of the bromide each day. The fits recurred at each period 
 when menstruation ought to have appeared, so that on May 16th 
 I had recourse again to the galvanic stem. She menstruated 
 from the 20th to the 24th without any fit, and she wore the stem 
 with only very occasional fits, and with perfect and regular re- 
 currency of menstruation, till November, when the stem was 
 removed. By the following March, 1874, the fits had reappeared. 
 and the menstruation was again in abeyance, and just as it dis- 
 appeared the fits were re-established.
 
 106 DISEASES OP THE OVAEIES. 
 
 During 1875 I saw her only occasionally, as it was only 
 when she was worse than usual that she came for the bromide 
 mixture. It was quite clear then that her mental qualities were 
 becoming dulled, and she was rapidly taking on the character- 
 istic face of an epileptic imbecile. During 1876 another effort to 
 re-establish the periods by means of the galvanic stems was 
 made, but with results less satisfactory than those made in pre- 
 vious years. On February 5, 1877, I was asked to see her at her 
 own house, and found her in a condition of epileptic mania. 
 I advised her removal to an asylum, but her husband and mother 
 declined to act upon my suggestion, despite its being quite evi- 
 dent to them that the injuries she inflicted upon herself during 
 the fits were of so serious a character as to endanger her life, 
 and from her occasional violence during the delirium it was 
 quite possible she might become a homicide. Every month 
 the fits returned with increasing severity, and the attacks of 
 mania fastened themselves almost wholly upon the week, dur 
 ing which a slight loss, lasting for a few hours, indicated that 
 her menstruation should have occurred then. The bromide of 
 potash was pushed to as much as two hundred grains a day 
 without the slightest effect, and other drugs were tried equally 
 without avail. 
 
 In July, 1879, her condition was so dreadful that her friends 
 at last determined to send her to an asylum, and I saw her on 
 the 5Sth. She was almost completely fatuous, her memory was 
 almost gone, the fits seemed to miss only one week in four, the 
 attacks of mania were irregular and continued for varying pe- 
 riods, and menstruation occurred at irregular times. Yet, on the 
 whole, it Avas said by her mother that she was at her worst very 
 regularly one week out of the four. 
 
 It occurred to me that, if my view were correct, that this was 
 a case of menstrual epilepsy really depending upon exanthe- 
 matic cirrhosis of the ovary, removal of the ovaries — an operation 
 of very ancient date, and which I performed for the first time in 
 this country in 1872 — held out some prospect of curing this un- 
 happy woman. At least it could not make her worse than she 
 was, for, even if she died under it, the release would be a grateful 
 one to all concerned. Her relatives, therefore, gave a ready con- 
 sent to my proposal when I laid it, and the reasoning upon which 
 I based it, before tliern. 
 
 I therefore admitted the patient to the Women's Hospital, 
 and, with the concurrence of my colleagues, I removed the ova- 
 ries on August 11th. 
 
 This operation — according to my experience one of the most 
 successful operations in surgery, and likely to prove of infinite
 
 OOPHORITIS AND PERI-OOPHOKITIS — ABSCESS OF OVARY. 107 
 
 service to suffering women — was first performed in 1873 by Pro- 
 fessor Hegar, of Leipsic, and he first published his proposal. 
 Within a very few days after Professor Hegar's operation it was 
 performed here by myself, some months before Professor Hegar's 
 account of his case reached this country. Dr. Battey, whose 
 name it is proposed to fix upon this operation, did not operate 
 till after Hegar and myself, and his publication was also subse- 
 quent to both of ours. 
 
 The operation in the case of E. E was made somewhat 
 
 difficult by her being extremely fat. A somewhat profuse cata- 
 menial flow set in on the third day after the operation, and lasted 
 for three days, but without the slightest appearance of a fit. 
 This pseudo-menstruation is very common after ovarian opera- 
 tions, and often recurs for two or three months after removal of 
 both ovaries. 
 
 The stitches were removed on the 18th, and she sat up on the 
 23d of August, twelve days after the operation. 
 
 I went away for my holiday, and did not return till the 20th 
 of September, when I found her an altogether different woman. 
 She had had no fits, no more menstruation, was bright and cheer- 
 
 >^ 
 
 Fio. 24. — Exautheniatic ciiThosis of ovary. 
 
 ful in her face, her memory returning, and she had altogether 
 lost the dull, heavy, epileptic look which she had before. 
 
 I last saw her on October 13th, when she was about to go to 
 her home in Peterborough, and she and her friends were satisfied 
 as to her perfect recovery, and were as grateful as people could 
 be for the improvement in the patient's condition. 
 
 One question of course remains : Will the improvement be 
 permanent ? I do not know. It seems almost too much to hope 
 for, but I really think it will be. The description of the ovaries 
 by my friend, Mr. Alban Doran, completely justifies my view of 
 the pathology of the case, and my treatment is but a logical con-
 
 108 
 
 DISEASES OF THE OVARIES. 
 
 elusion from that view. After such an operation one would 
 expect that the fits would probably continue for a few months, 
 and gradually disappear. But here they have disappeared at a 
 blow, and, after nearly three months' absence, I think they may 
 be expected to have finally disappeared. 
 
 The ovaries removed were not much smaller than normal 
 ovaries, but they were fissured in a most remarkable manner, so 
 as to resemble in miniature the kidneys of an ox, or the convolu- 
 tions of the human brain. I sent one up to the College of Sur- 
 geons' Museum, and I quote from Mr. Doran's report upon it, as 
 follows : 
 
 •" There are no signs of 'alveolar degeneration,' but the elon- 
 gated cells of the stroma are larger than in normal ovaries, and 
 
 mmi^^s 
 
 Fig. 25 (drawn by Mr. Alban Uoraii). — iIicro>copic appearances of cirrhotic ovary, magnified diame- 
 ters : a. Normal arteriole ; b, small vessel occluded ; c, c, debris, i)robably site of vessels occluded by pres- 
 sure of new cellular tissue. 
 
 there are few vessels; the hypertrophy of those that remain, and 
 the bundles of fibrous tissue, point to a cirrhotic change follow- 
 ing the exanthematic oophoritis. There were no morbid cysts, 
 nor extravasation of blood ; no pathological breaking down. 
 There were two Graafian vesicles, eacli about one-twentieth of 
 an inch in diameter, both close to the surface, the periphery of 
 the ovary being slightly denser than the deeper stroma, to the 
 depth of one-eighth of an inch. Near the inner extremity of the 
 ovary is a menstrual corpus luteum which makes a distinct bulge 
 on the surface."
 
 OOPHORITIS AISTD PERI- OOPHORITIS — ABSCESS OF OVARY. 101> 
 
 I cannot conclude the notes of this case without restating my 
 belief that, in this operation for the removal of the uterine ap- 
 pendages, we have the means of alleviating an enormous amount 
 of suffering of an otherwise incurable kind. 
 
 The conclusions which I have made concerning the influences 
 of exanthematic diseases upon the ovaries have already been 
 confirmed by many interesting observations, chiefly by Dr. Lebe- 
 dinsky. In the specimens he has examined during the actual 
 process of inflammation, he describes the macroscopic appear- 
 ances as unchanged both on the surface and in section. He ex- 
 amined the ovaries after having hardened them in Miiller's 
 fluid and afterward in alcohol and picric acid. He found, on 
 section, that all the Graafian follicles were in a condition of pa- 
 renchymatous inflammation, which commenced in turbid swell- 
 ing of the epithelium, and proceeded to the complete destruction 
 of the cells. The ovarial stroma was not affected beyond being 
 hypergemic in the neighborhood of some of the follicles. He 
 found the destruction of the glandular tissue most marked in the 
 case of a girl eight years of age, who, during her convalescence 
 from scarlet fever, was attacked by measles, of which she died 
 on the eighth day. Tlie great majority of the follicles in the 
 ovaries of this patient were occupied by a finely granular, struc- 
 tureless material, and in the cortical layer the follicles seem to 
 have been almost entirely destroyed. Lebedinsky regards this 
 affection of the ovaries as being quite analogous to the well- 
 known parenchymatous inflammations of other organs during 
 the progress of infectious diseases. The result is a destruction 
 of a larger or smaller number of follicles, and the consequent in- 
 terference with the subsequent function of the ovaries in corre- 
 sponding degree, so that the fecundity of the infected person 
 will, in severe cases, be rendered extremely problematical, and 
 this will be a certain result if the tubes are also found to have 
 been damaged. This is the case in by far the larger number of 
 cases, and the tubes share in the general atrophy of the parts in 
 the subsequent cirrhotic change. 
 
 As I have already indicated, chronic ovaritis may be a later 
 stage of moliminal hypersemia. It may also be the result of 
 acute ovaritis ; but the majority of the cases occur from sexual 
 excess and masturbation, or as a sequela of exanthemata and 
 rheumatic fever, and probably of syphilis. I have only once had 
 an opportunity of dissecting a case where I had recognized 
 chronic ovaritis in life, and then it certainly was the result of 
 acute rheumatism. It occurred in the case of a girl seventeen 
 years old, who had suffered from eight or nine attacks of rheu- 
 matic fever. In two of them she was under my care as a dispen-
 
 110 DISEASES OF THE OVARIES. 
 
 sary patient ; and after the recession of the articular affection 
 an attack of pelvic pain came on, which was increased by pres- 
 sure, and the attack was accompanied by an irregular menstrual 
 flow. The whole passed off in a few days after the application 
 of a blister, but ever afterward her menstruation was irregular, 
 profuse, and painful, and she suffered more or less from the 
 symptoms I shall describe immediately. I regarded the attack 
 as one of mild acute or subacute ovaritis, followed by a chronic 
 stage. She died subsequently of embolism of a cerebral artery, 
 and I found her ovaries large, soft, covered with lymph, and 
 dotted with enlarged follicles, and the peritoneum was thickened 
 around them. The left ovary was partly adherent to the rectum, 
 and it had nearly the whole of the fimbrise of the corresponding 
 tube glued on to it. 
 
 The following case illustrates the same lesion in a more 
 chronic stage of its progress : 
 
 H. B , aged thirty, was placed under my care in Septem- 
 ber by Dr. Bradley, of Dudley, who told me that when she came 
 under his care she had retroflexion and a variety of somewhat 
 severe symptoms, including pains in the groins, extending down 
 both thighs and into the back, which were much worse just be- 
 fore the menstrual period. He remedied the retroflexion by one 
 of Graily Hewitt's pessaries, but the pains still continued as bad 
 as before, and he sent her to me with a letter containing this 
 sentence : ''It seems to me that, in order to completely cure her, 
 it might be necessary to remove one or both ovaries." 
 
 The history that she gave was as follows : Her menstruation 
 began at the age of fourteen, and was at first regular and nor- 
 mal. At the age of eighteen, while resident in Paris, she had 
 an attack of rheumatic pleuro-pneumonia, and after that she did 
 not menstruate for seven months. It is not quite clear, but I 
 think it more than likely that at this time she had an attack of 
 ovaritis, because, during her convalescence, she found that she 
 could not for many months straighten herself on account of se- 
 vere pelvic pains, which existed on both sides, and extended 
 down the thighs, and which prevented her walking any distance 
 for a long time. At the end of the seven months she got some- 
 what better, and her periods returned, but she suffered intense 
 pain while they were on. Three years before I saw her, while 
 resident in Poland, she had a severe attack of pelvic inflamma- 
 tion, which was at the time regarded as being of ^a rheumatic 
 character. Since that attack her menstruation has always been 
 extremely irregular and very painful, so that practically for three 
 weeks in every month she has been wholly unable to do any-
 
 OOPHOKITIS AJSTD PEKI-OOPIIOKITIS — ABSCESS OF OVARY. Ill 
 
 thing, or even to walk, and for two years previous to my seeing 
 her she had not been able to follow her occupation of a governess. 
 I found the uterus fairly normal in position, and dow^n behind 
 it and on either side the ovaries could be felt, large and nodular, 
 just like mulberries. They were extremely tender and evidently 
 adherent. After some further discussion with Dr. Bradley, it 
 was deterinined to remove the organs, and this operation I per- 
 formed on October 26, 1880. I found the ovaries adherent, nodu- 
 lated, studded with minute cysts, and markedly cirrhotic ; they 
 were very friable, and their removal was a matter of great diffi- 
 culty. With them I removed the adherent tubes. She recovered 
 rapidly, but unfortunately during the process of recovery she 
 had a hsematocele, and though she has improved steadily since 
 the operation, her progress has been, on account of this accident, 
 neither so rapid nor so satisfactory as I could wish, nor as has 
 been the rule in most of my cases. The condition of her ovaries 
 very well illustrates the result of the interstitial form of oopho- 
 ritis which is a result of rheumatic disease. 
 
 Speaking of chronic ovaritis. Dr. Mathews Duncan gives the 
 following valuable evidence, which I quote in full on account of 
 the precision of the language, the eminence of the author, and 
 most of all because, as Dr. Mathews Duncan does not practise 
 surgery, he may be expected to give his opinions without surgi- 
 cal bias : 
 
 "These cases, indeed, generally resist all treatment. Here 
 
 is a case : A. H , aged twenty-four, married a year and a half, 
 
 never pregnant ; catamenia regular. She complains of painful 
 menstruation. On examination the left ovary is easily felt, and 
 somewhat swollen and tender. The uterus is natural, except 
 extreme sensitiveness of the mucous membrane of its body. The 
 ■cervix permits easily the passage of only a No. 7 bougie. After 
 some partially successful treatment of the dysmenorrhoea, she 
 left the hospital, but soon returned, saying she was not cured. 
 Now, she privately made known that what she wished cured was 
 not so much her painful menstruation as pain in sexual connec- 
 tion, a pain which delicacy had prevented her from earlier men- 
 tioning. With this in view she was re-examined, and now both 
 ovaries, somewhat prolapsed, swollen, and tender, yet freely 
 mobile, were easily felt. Pressure on either of them produced 
 pain, which she recognized as that of her dyspareunia. She is 
 now under treatment. Counter-irritants externally, and small 
 doses of corrosive sublimate internally, are being used. I can 
 only say I hope she will be cured." 
 
 Here, then, we are dealing: with a disease which one of the
 
 112 DISEASES OF THE OVARIES. 
 
 greatest living gynecologists frankly admits is almost incurable. 
 In hospital practice I assert that it is absolutely incurable in by 
 far the greater number of cases. The only means of arriving at 
 so satisfactory a result is limited to the classes possessing wealth 
 and education, for with them alone is it possible to secure the 
 obedience to directions and the perseverance in treatment by 
 w^hich it is possible occasionally to get a cure. More than this, 
 it is only in a life of luxury that it is possible to prevent the re- 
 lapses to which this disease is so liable. 
 
 The symptoms of the disease vary very considerably, yet 
 there are certain features common to all the cases which are 
 sufficiently definite for reliance to be placed upon them for pur- 
 poses of diagnosis. 
 
 Pain is an inevitable feature, and nineteen times out of 
 twenty it is worse on the left side than on the right ; and if it 
 exist on one side only, it is almost certain to be the left which is 
 affected. The explanation ^vhich I offer of this peculiarity will 
 be found in the first chapter (p. 8). 
 
 This pain is always referred to the groin as the point of origin 
 and of its greatest intensity. It is nearly always persistent, and 
 liable to exacerbation when the patient is in the erect position — 
 when walking, but more particularly when being jolted in a car- 
 riage. It also becomes more intense as the organs become con- 
 gested at the monthly periods. When the pain is intensified 
 from any cause, it extends from its habitual seat down the thighs 
 and round into the back, and very often a reflex pain is excited 
 in the breast of the same side. Sometimes the pain is so great 
 as to prevent the patient straightening herself, and obliges her to 
 walk what little she does in a semi-bent attitude. Pressure upon 
 the seat of pain ahva^'s increases it, and the slightest touch on 
 the ovary from the vagina gives rise to a peculiar sickening sen- 
 sation which is very characteristic. For this reason, and also 
 from the fact that her chronically inflamed ovary is nearly al- 
 ways displaced downward, marital intercourse is generally a 
 cause of great pain, and. in the majorit}^ of instances, is abso- 
 lutely unendurable. Generally speaking, the pain lasts through- 
 out the whole period of menstruation ; but in some instances it 
 varies in this particular, for in some of the most pronounced 
 cases of chronic ovaritis that I have seen, the pain ceased, or at 
 least was greatly diminished, on the appearance of the menstrual 
 flow. 
 
 Menstruation itself is, in most cases, profuse, but in some of 
 the cases I have already detailed this profuse metrorrhagia is 
 due not so much, perhaps, to the ovaritis as to the fundal metri- 
 tis and the inflammation of the tubes with which it was associ-
 
 OOPHORITIS AND PERI-OOPHOKITIS — ABSCESS OF OVARY. 113 
 
 ated, and it has been the chief cause for interference by surgical 
 operation. Those cases in which hemorrhage is a characteristic 
 are, I believe, those in which the inflammation is of an intersti- 
 tial character, and probably not of that kind in which the cir- 
 rliotic change subsequently occurs. I have found that, in tlie 
 cirrhotic cases, there is less inflammation of the other organs, 
 and generally an atrophy of them, as of the ovary itself in the 
 later stages ; and that, as a consequence, the periods, instead of 
 being profuse, become rather scanty. It is in the former cases 
 that we find the ovary studded with small cysts, whereas in the 
 others the increase in the size of the ovary is of the solid kind. 
 
 But as yet there is not, either in my own practice or in that 
 of any others yet published, any sufiiciently precise data upon 
 which an absolute conclusion in this matter may be founded ; 
 indeed, it has only been of very recent time that we have been 
 able to see these diseased ovaries in cases where the clinical his- 
 tory was accurately known. Our experience is as yet insufficient 
 to warrant us in asserting any positive conclusion. 
 
 It is, however, perfectly certain that there are two kinds of 
 pathological appearances produced by chronic ovaritis, and these 
 are probably the result of two wholly different morbid processes. 
 It is in the cases where we have a cyst-production that we have 
 the most adhesions formed, and I think, from what I have al- 
 ready seen, that it is very likely that these adhesions are pro- 
 duced by limited inflammations resulting from the rupture of 
 these small cysts. This phenomenon was originally described 
 by Dr. Mathews Duncan, and I have seen the results of it, I be- 
 lieve, in several instances, and, in one of my cases, I have twice 
 been quite certain, from the completely altered condition of the 
 ovary at separate examinations, that such ruptures must have 
 taken place. I have so often seen these cysts rupture immedi- 
 ately the ovary was touched, that I can have no doubt of the ac- 
 curacy of Dr. Duncan's description. I exhibited a specimen re- 
 cently to the Pathological Society of a cyst of the Fallopian tube, 
 which I had recognized as having repeatedly been the subject of 
 rupture, each rupture being followed by an attack of acute peri- 
 tonitis. The specimen was obtained on post-mortem examina- 
 tion, after the sudden death of the patient. 
 
 The physical examination of a case of this kind requires to be 
 conducted with a great deal of care, for nothing disappoints a 
 suffering woman more than to have her pain increased by rough 
 handling. When, therefore, the practitioner hears a narration of 
 such symptoms as I have described, let him be careful how, by 
 his finger, or the sound, or the speculum, he injures a displaced 
 and inflamed ovary or tube. It will, as I liave already said, be 
 8
 
 114 . DISEASES OF THE OVARIES. 
 
 easily found behind, and about on a level with, the upper part 
 of the cervix. A careless observer may mistake it for a retro- 
 fleeted fundus, and introduce a pessary for its replacement ; but 
 this will prove to be nearly always a source of disappointment ; 
 indeed, as I have already said, it may be a source of danger. 
 Besides the symptoms of inflammation of the ovary in a chronic 
 case, there are symptoms of uterine complication, and a very 
 great many of the cases of intractable endometritis met with in 
 practice are really but expressions of the same serious disease. 
 
 For the treatment of this disease the most important of all 
 considerations is physiological rest. For this purpose the wo- 
 man must regard herself as an absolute invalid during her men- 
 strual week, remaining in bed the whole of that time. This con- 
 dition at once separates the hospital from the private patient, 
 and therefore we find that, while in hospital practice it is almost 
 impossible to permanently cure a case of chronic ovaritis, yet, in 
 many of our cases in private practice, a cure may be accom- 
 plished by patience and perscA^erance. Besides the menstrual 
 rest, there should be complete cessation of marital intercourse. 
 If it be found that the ovary is displaced and not adherent, it 
 may be replaced by pessary or the genupectoral position, as al- 
 ready described (in the chapter on ovarian displacements). Over 
 the groin counter-irritation should be employed by means of blis- 
 ters of iodine or cantharides. my favorite formula being a mix- 
 ture of equal parts of the tincture and liniment of iodine (B. P.), 
 to be painted on over the groin every morning, as long as the 
 skin will stand it. When it can no longer be borne, the skin is 
 allowed to peel off and become again quite fresh, and after that 
 the processes are to be repeated for some months. Of internal 
 remedies, the only drugs which I have seen of the slightest ser- 
 vice are bromide and chlorate of potash, and nux vomica. These 
 I generally give in combination, or alternately, the patient taking 
 from fifteen to twenty grains of the bromide or of the chlorate 
 for a month, and then the nux vomica for a month. 
 
 In these cases I never give iron when there is any tendency 
 to hemorrhage, or, indeed, in any other condition when that 
 symptom is prominent. I have always found iron do harm then; 
 and in support of my views upon this point, which have been 
 very adversely criticised, I cannot do better than quote Dr. Alfred 
 Meadows : ''I do not think I at all exaggerate wheii I say that, 
 in ninety-nine out of every hundred cases of monorrhagia which 
 come before the practitioner for treatment, his first thought is. 
 What form of astringent shall I give ? And the answer proba- 
 bly in most cases will be, an astringent chalybeate — either the 
 perchloride or the pemiti'ate ; or some similar preparation of iron
 
 OOPHOKITIS AND PERI-OOPHORITIS — ABSCESS OF OVARY. 115 
 
 will be almost certainly prescribed. No wonder that such rou- 
 tine practice frequently fails ; for a very considerable number 
 of cases of monorrhagia which come up for treatment are of the 
 kind we have been considering, and for such as these the per- 
 salts of iron are worse than useless ; their only effect will prob- 
 ably be to aggravate the complaint." The paper from which I 
 quote Dr. Meadows' words is one on " Ovarian Menorrhagia."* 
 
 Among our private patients, in spite of every kind of treat- 
 ment, no matter how long a time it may be continued, we shall 
 find a few cases in which no good result is obtained, and these 
 can only be dealt with by the last resort of a surgical operation. 
 Among our hospital patients, on the contrary, the cures are ex- 
 ceptional and the failures are the rule, solely for the reason that 
 these poor women cannot fulfil the necessary conditions. This 
 part of the treatment I shall discuss at length in the chapter on 
 ovariotomy. 
 
 As one of the results of chronic ovaritis, we get pronounced 
 hypertrophy of the glands, and this occurs distinctly in two 
 forms, as it affects the follicles of the gland or its fibrous tissue. 
 There may be, as Dr. Ritchie and Dr. Fox have pointed out, an 
 increased formation of the number of follicles ; this, in all prob- 
 ability, being a pathological feature of the ovarian hyperyemia I 
 have described. Follicular hypertrophy may take the form of 
 increase in size of individual follicles, and constitute, as first 
 shown by Rokitansky, a variety of cystic growth ; and this is, 
 as both Dr. Duncan and myself have pointed out, a frequent 
 character of the ovaries, which have to be removed on account 
 of the suffering inflicted by chronic ovaritis. 
 
 In fact, there seems to be a close and hitherto unsuspected 
 connection between cystic disease of the ovary and some of the 
 most severe uterine symptoms that patients suffer from. Thus, 
 I have removed the ovaries of a large number of women suffer- 
 ing from profuse and destructive hemorrhage, due to the pres- 
 ence of uterine myoma, and in the majority of these cases I have 
 found the ovaries cystic. But it may be noticed that these cysts 
 have not always been like the large tumors for which we per- 
 form ovariotomy, and the ovaries containing them have very 
 often been no larger than walnuts. In them the ovarian tissue 
 had been replaced by cysts, and when those cysts were emptied 
 there was very little left besides their walls. On the other hand, 
 some of the cystic ovaries in these cases of myoma had attained 
 quite a large size, so that there has arisen a difficulty in deciding 
 as to whether one was operating for the removal of cystic ova- 
 I'ies, or removing the ovaries for the purpose of arresting hemor- 
 rhage in cases of myoma. Indeed, the difficulty was to say
 
 116 . DISEASES OF THE OVARIES. 
 
 whether it was a case of ovariotomy or the so-called " oophorec- 
 tomy." The result has been, as I shall state at length in another 
 chapter, that I have completely discarded the use of this latter 
 term, because, unless some kind of conventional distinction is 
 made, it will be perfectly impossible to classify our cases in any 
 logical manner, or for any useful purpose. 
 
 These small cj'stic ovaries very often give rise to extremely 
 severe hemorrhage, even when there is no myoma present, and 
 when there is no suspicion of any chronic inflammation of the 
 glands. The size of the ovaries is not great enough to justify us 
 in calling them ovarian tumors, and it is highly probable they 
 are nothing more than follicular hypertrophies. Of this peculiar 
 condition I propose here to give in detail three instances. 
 
 In June, 1880. 1 was called by Dr. CoUis. of Bridgenorth, to see 
 with him. in consultation, a lady of very eminent social position. 
 on account of persistent metrorrhagia. She was twenty-nine 
 years of age. She had been married six years, and before that 
 had suffered always more or less from a white discharge and ir- 
 regular and profuse menstruation. Kine months after marriage 
 she was confined of a still-born child, and nearly lost her life 
 from hemorrhage. Two years after she had another child, liv- 
 ing, and in the following jeav another child, both labors being 
 characterized by unusual hemorrhage. In 1878 she had a mis- 
 carriage, and was alarmingly ill from hemorrhage. In August, 
 1879, a third child was born, about six weeks before the full time,, 
 when again the hemorrhage was extreme. 
 
 Dr. Collis has favored me with the following notes of the 
 progress of this most interesting case : He saw her first on May 
 31, 1880, when he was informed that, up to a fortnight before 
 his visit, she had missed three menstrual periods, but that during 
 the fortnight there had been a continuous flow. Neither she nor 
 her husband thought it possible that she was pregnant. They 
 regarded it as her usual profuse and protracted menstruation ; 
 but on examination Dr. Collis found the uterus enlarged. He 
 kept her in bed and gave her astringents, and afterward ergot 
 and bromide of potash. Finally he had to plug the vagina, and 
 then he telegraphed for me to see her with him. I saw her on 
 the evening of June 13th, and found the patient very anaemic, 
 and the uterus enlarged as if by a pregnancy of the third month. 
 The cervix being closed, it was clear that we must dilate, and 
 for that purpose I introduced my instruments, which act by con- 
 tinuous elastic pressure. In a few hours dilatation had jDroceeded 
 so far that, after placing the patient under ether, I was able to 
 empty the uterus of a large quantity of clot and some villous
 
 OOPliOKlTIS AND PEKI-UOPIIOEITIS — ABSCESS OF OVAEY. 117 
 
 cysts. These, I presume, were remains of a chorion of which 
 the villi had undergone cystic dilatation, but nothing in the shape 
 of membranous or placental structure could be discovered. Rec- 
 ognizing the urgent necessity of there being no more hemor- 
 rhage, I took great pains to remove everything from the uterus, 
 and I scraped the whole of the inner surface over with a curette. 
 She had no further loss, and made a good recovery till July 10th, 
 when her period came on very profusely, lasted ten days, and 
 left her very ant3emic and exhausted. During the whole time 
 she took large doses of bromide of potash and ergot, but with no 
 apparent effect. Hemorrhage again occurred on July 29th, by 
 which time she had been removed to Malvern, where she was 
 under the care of Drs. Pike and Weir. The hemorrhage was 
 -extreme, and everything was tried, including hypodermic injec- 
 tions of ergotin, without any avail. I was sent for on August 
 3d. and found the patient in the very last stage of angemic ex- 
 haustion. I removed a plug which had been placed in the va- 
 g;ina, found the uterus perfectly small and normal, explored it 
 with the alligator-forceps, but found nothing in it, and then I 
 applied solid nitrate of silver freely to the inside. This stopped 
 the hemorrhage for about twenty hours, but after that it came 
 on, and I was sent for again on the 6th. At my visit on the 3d 
 I had informed the husband that, if the nitrate of silver did not 
 check the hemorrhage, I knew nothing short of a surgical opera- 
 tion which would, but said nothing to him as to the nature of the 
 operation I intended to perform. When telegraphed for on the 
 6th, I replied that I should bring my assistant and everything 
 prepared to operate if it was thought desirable, and for this pur- 
 pose my friend. Dr. J. W. Taylor, accompanied me to Malvern, 
 in the absence of Mr. Raffles Harmar. 
 
 When I reached the house I met the husband, a man of dis- 
 tinguished position and great intelligence, at the door. He 
 greeted me with the remark that he did not know what I pro- 
 posed to do, that he left it entirely to me, but that he was per- 
 fectly sure the only thing which Avould give either temporary or 
 permanent relief would be removal of the appendages. As this 
 was exactly my own notion, and was readily agreed to by my 
 colleagues in the case, I at once proceeded to carry it out, my only 
 fear being that we had delayed it too long. She was blanched 
 beyond my powers of language to describe, and she had those 
 swollen, waxy lips which are rarely restored to their original 
 condition. There was no difficulty in the operation, and both 
 ovaries were found to be cystic, and about the size of Mandarin 
 oranges. The uterus was perfectly normal in size and consis- 
 tence when I had it between my fingers. The incision was only
 
 118 DISEASES OF THE OVAEIES. 
 
 two and one-half inches long, and its bleeding points were indi- 
 cated by a flow of serum almost devoid of color. For about an 
 hour after the operation I gave up almost all hope of her recov- 
 ery. Dr. Pike and I were in almost constant attendance upon 
 her for five days, during which she had some ups and downs, 
 but finally she got right, and has never lost a drop of blood since. 
 She has had the usual flushes and other slight indications of the 
 climacteric, but these are wearing off ; and in the last letter I 
 have had from her husband, a few days ago, is the sentence: ''It 
 only remains for me to express our united gratitude for your 
 skill and attention ; for, humanly speaking, I shall always look 
 upon you as her saviour." 
 
 Putting aside, as far as possible, all personal gratification at 
 such an expression, I desire only to put in this evidence given by 
 a highly educated layman, fully conversant with his wife's con- 
 dition and what was done for her, in favor of an operation upon 
 which only those who have not successfully tried it are endeav- 
 oring to cast obloquy. The only credit in this case I desire to 
 assume is, that I had the courage of my convictions, and that I 
 proceeded, as a last resource, to a step which, if I had regard to 
 metropolitan opinions, I should not have attempted. Had the 
 case been unsuccessful, the position of the patient was such that 
 the proceeding would have been widely, and I fear adversely,, 
 criticised. 
 
 Looking at the ovaries of this case, I notice that there is little, 
 if any real ovarian tissue left. There is hardly anything but the 
 thin walls of a number of dilated follicles, from which it is very 
 difficult to believe that a healthy ovum could be sent into the 
 tube. This naturally raises the question as to whether the im- 
 perfect ovulation, which was the first cause of my being sent for 
 to her, was the result of this follicular hypertrophy. I think it 
 very likely that it was so. The condition seen in these, ovaries 
 must, I think, be something special, and not merely the early 
 stage of cystoma, for I never hear such a terrible story of hem- 
 orrhage from the lips of a patient in whom an ordinary C3^stoma 
 has grown, as I have to narrate about the three cases in whom 
 I found these small cystic ovaries, and from whom I removed 
 them with perfect success. 
 
 The second case was in some respects more remarkable than 
 the first, though it is not necessary to occupy so much space 
 with its detail. She was thirty-nine years of age, had been 
 married at fourteen years of age. and was confined of her first 
 child before she was sixteen, her second at seventeen ; eight
 
 OOPHORITIS AND PEKI-OOPHOKITIS— AHS(JES8 OF OVAKY. 119 
 
 months after she had a miscarriage, and then for the next ten 
 years had a baby every year. At each confinement the hem- 
 orrhage was very great, and two or three times she was sup- 
 posed to be dying from this cause. As she had had no menstrua- 
 tion for twelve years, being either always pregnant or suckling, 
 she could tell nothing about this matter until she became a 
 widow at twenty-eight. She married again about four years 
 ago, and during her widowhood her menstruation had been far 
 too frequent and too profuse, and she had been almost con- 
 stantly in the doctors hands on that account. Since her recent 
 marriage she has had eight miscarriages in forty months, the 
 first being at seven months and the others between four and five. 
 She was admitted into the hospital in February last, when preg- 
 nant at the third month. She was put upon chlorate of potash 
 and biniodide of mercury, in order to avoid the repetition of the 
 miscarriage, and slie took every precaution to assist us in this, 
 for both she and her husband were very anxious for a living 
 child. In spite of everything, however, she miscarried at the 
 fifth month, and as nearly as possible died from the hemorrhage. 
 During May, June, and July she had most profuse menstruation, 
 though active treatment was employed, and when admitted into 
 hospital again she was a completely broken-down ansemic wo- 
 man, whose desire was to die if nothing more could be done for 
 her. In this case it did not occur to me to remove the appendages, 
 and that proposal originated with my colleague. Dr. Hickinbo- 
 tham, at the consultation held on the case. I am bound to say 
 I did not regard the idea with favor at first, and it was only after 
 prolonged discussion with my colleagues, and finally at tlie ear- 
 nest and frequently repeated request of the patient herself, that 
 I undertook it. This request was based on her knowledge de- 
 rived from a patient in the same ward who was recovering from 
 the operation. Here again the ovaries were cystic, just as in 
 the first case, the cysts being small and thin-walled, but occupy- 
 ing the whole of the ovary. We may again ask. Did they ac- 
 count for the repeated incomplete ovulation, as well as the hem- 
 orrhage ? Such a question needs a much wider experience for 
 its solution. Whatever be the explanation, the result is brilliant, 
 for the woman made a speedy recovery, and now, not yet twelve 
 months since the operation, is in robust health— such health, in 
 fact, as she has never known before. 
 
 The third case was sent to me by Dr. Meredith, of Wel- 
 lington, in Somersetshire, and I give the history in his own 
 words : 
 
 " In May, 1877, I had to attend a young woman, aged twenty.
 
 120 DISEASES OF THE OVARIES. 
 
 on account of excessive menstrual discharge, which had been 
 going on for some weeks. 
 
 "The previous history of the case was briefly this : The pa- 
 tient, as a girl, had always been considered delicate up to the 
 menstrual period — which, with her, began when she was fifteen 
 — although she was well-formed and tall. Once the courses be- 
 came established, she began to gain strength and fatten. The 
 catamenia were regular, but scanty, only about three diapers at 
 a period ; still she felt well, and gave this no particular thought. 
 Her parents are healthy, and so are her brothers and sisters. 
 One day in March of the year mentioned (1877), while menstru- 
 ating, she assisted in lifting a book-case. She felt the efi&ort af- 
 fecting her, and the discharge, instead of terminating at the ex- 
 pected time, went on day after day. 
 
 " When I saw her she was in an exhausted condition from the 
 loss, and suffering pain, etc., in the lower part of the abdomen, 
 indicating the presence of a certain amount of local inflamma- 
 tory action. After the administration of opiates this condition 
 of irritability subsided, and after a Avhile I obtained permission 
 to make a digital examination of the vagina and cervix uteri. 
 
 '* The information I got from this was that there was no 
 appreciable difficulty in introducing the finger ; the os uteri was 
 patulous, with a blood-clot in it, and the cervix elongated. There 
 was nothing special to note in regard to the condition of the 
 uterus — no marked version or flexion. Now, a very natural 
 question suggested itself, and I have no doubt it arises at once 
 in your minds, namely. Was not the case one of miscarriage ? 
 A question which I put to the patient some time afterward, bear- 
 ing on this, was met by a negative answer — just what I might 
 have expected. But my duty was to arrest the hemorrhage and 
 bring about recovery, if I could. To this end I administered 
 ergot, acids, bromide of potassium, chlorate of potash, digitalis, 
 and cannabis indica. The last-named three, in combination, 
 seemed to answer well for a while, then there would be a relapse. 
 Cloths dipped in vinegar and water were applied over the vulva 
 and lower part of the abdomen : cold water, vinegar and water, 
 and carbolic acid solution were at intervals injected into the va- 
 j;ina, and, of course, absolute rest in bed was enjoined, witL 
 everything cold in the way of food and drink. 
 
 " In spite of everything, the discharge continued more or less 
 until July. At times there would be nothing but a pink, san- 
 {.ruineous staining on the cloth. The patient soon learned to dis- 
 iike this appearance, as she had always a great deal of backache 
 v/ith it, from which she was only relieved after the expulsion of 
 l>]ood-clots. The explanation of this, I take it, was that the clo6
 
 OOPIIOKITIS AND PEKI-OOrilORITlS — ABSCESS OF OVAKY. 121 
 
 formed in the os uteri, and, owing to the flow not being enough 
 at times to carry itself off as a whole, the fibrin separated at the 
 uterine outlet and in the uterus as well, staying there gathering 
 in volume, while the liquor sanguinis escaped, and produced the 
 stains mentioned. The fibrinous part, in thickening, rested upon 
 the walls of the os, distending it, and, as in labor or any other 
 form of tension at the os uteri, the discomfort was referred to 
 the sacral region — the region of backache with many women. 
 After going on in this way for a time, I decided to apply pure 
 carbolic acid to the interior of the uterus. I did this in the usual 
 way, by means of a piece of cotton-wool wrapped around an or- 
 dinary uterine sound. The result was satisfactory for the time ; 
 the discharge stopped for five months, the patient recovered 
 strength, and was able again to go about and enjoy herself. 
 
 " In the beginning of 1878 the menses reappeared, but nothing 
 much to complain of at first ; then the loss assumed a more per- 
 sistent character. Drugs seemed to have very little influence 
 now, nor had the intra-uterine application of carbolic acid the 
 same arresting influence as at first ; still it exercised a certain 
 amount of staying power. Thus matters went on unsatisfacto- 
 rily to all concerned. Toward the end of 1878 the loss was not 
 very great, still it recurred at short intervals ; but on Christmas 
 eve she got excited with some of her friends, and then it came 
 on profusely. There was always tenderness over the ovaries, at 
 times more over one than the other, and, of course, the usual 
 sympathetic tenderness along the spine. 
 
 " Finding that I was unable to afford the relief I wished, I 
 urged the patient to go to the Women's Hospital at Birmingham, 
 to be under the care of Mr. Lawson Tait, with wdiom I had had 
 some correspondence regarding the case. Accordingly, on Janu- 
 ary 15th she went thither. She was thin, weak, and anaemic at 
 the time. A few days afterward I had a note from Mr. Tait, 
 saying that he had dilated the uterus and thoroughly explored 
 it, and could find nothing amiss with it, only that the fundus 
 was a little enlarged, nothing more. 
 
 " A few days after admission, nitrate of silver was applied to 
 the cavity of the womb, and repeated three times between that 
 and February 15th. On the 10th the loss ceased, and no further 
 application was made. The patient had mixtures given her, con^ 
 sisting of ergot, bromide of potassium or chlorate of potash, and, 
 after the cessation of the discharge, dialyzed iron. 
 
 "She left the hospital, apparently recovered, on March 1st, and 
 went to a convalescent home, where she stayed for some time and 
 was much improved. In due course she returned home to Well- 
 ington. On the night of her return the discharge began again.
 
 122 DISEASES OF THE OVARIES. 
 
 " I knew nothing of her return, or of the recurrence of the dis- 
 charge, until she had been at home for some weeks. During the 
 interval she tried the effects of medicines which some neighbors 
 procured for her — getting into a sort of desperation-state, which 
 we can all pardon under the circumstances. I now tried the ef- 
 fects of cold water hip-baths, and with some apparent good re- 
 sults. Mustard poultices over the ovaries were followed by no 
 marked benefit. Swabbing the interior of the uterus produced 
 some relief. After a time I introduced a piece of nitrate of silver 
 into the cavity of the uterus, and left it there. This altered the 
 character of the discharge; but, in spite of all, the loss persisted. 
 I frequently left her alone, desiring her to keep still and take no 
 medicines at all; the result was the same — always losing. 
 
 " On July 0th last I gave her a hypodermic injection of ergo- 
 tine, which was followed by a stoppage of the discharge for 
 about three weeks. On August 5th I again sent her to the Wo- 
 men's Hospital at Birmingham, imder the care of Mr. Tait. At 
 the time the patient was amemic, tliin, and weak, and hardly 
 able to stand." 
 
 I re-admitted the patient in August, 1870, and removed botli 
 ovaries on the 8th of that month. The ovaries were large and 
 flabby, and occupied by a number of distended follicles forming 
 cysts. They were also chronically inflamed, for there was evi- 
 dence of old lymph here and there on their surfaces, and they 
 were somewhat adherent. The patient w ent home in a few weeks 
 after the operation, and speedily gained health and strength. 
 She has never menstruated since, and enjoys perfect health 
 (May, 1882). 
 
 From these cases I am forced to conclude that between these 
 small cystic ovaries and uncontrollable hemorrhage there is some 
 connection which has yet to be studied, and that in such cases 
 the removal of the ovaries is not only to be justified, but that it 
 is the proper proceeding, the results of these cases having been 
 brilliantly successful. 
 
 Besides this follicular hypertrophy, there is a distinct form of 
 fibrous hyperplasia which is probably the result of that form of 
 chronic ovaritis which attacks the fibrous element, and results in 
 follicular destruction or arrest of development of the proper ova- 
 rian cells, and produces an excess of the trabecular structure. 
 It is, in fact, the process of cirrhosis in its second stage, previous 
 to the contraction. The following is a case which I have had 
 the opportunity of watching for many years, and now seems to 
 be verging toward the cirrhotic condition. Both the patient 
 and I are agreed that if I could have done for her ten years ago
 
 OOPHOKITIS AND PERI-OOPHOEITIS — ABSCESS OF OVARY. 12:> 
 
 what I could do now, if it were as necessary, she would elect 
 to have her ovaries removed rather than pass through the pro- 
 longed invalidism to which she has been subjected. She belongs 
 to the upper ranks of life, and therefore has had every opportu- 
 nity of recovering, and no money has been spared to secure her 
 good health; yet she has been an invalid for about twelve years, 
 and is so yet, though enjoying better health than she did three 
 years ago. It would have been cheaper for her, and better in 
 every way, to have had her ovaries removed ten years ago. 
 
 She is now about thirty-eight years of age, is a pretty, deli- 
 cate blonde of nervous temperament and most refined cast of 
 features, and has been married about eight years. She has a 
 history of hypersemia of the ovaries at an early age, and has had 
 always very profuse, and generally irregular, menstruation until 
 within the last three or four years, when it has been scantier 
 and less frequent. From November, 1871, until she came under 
 my care, she had had only one normal period (in seven months), 
 and another in April, 1872. From the former date a constant, 
 offensive, brown discharge had been present, which was in- 
 creased by exertion. She had pain and strahiing after coitus, 
 pain on defecation, loss of appetite, and frequent sickness. Ex- 
 amination revealed a condition of enlargement and tenderness 
 of the uterus, openness of the cervix, and decided retroflexion of 
 the fundus, with a tendency to retroversion of the whole organ. 
 The cavity was not larger than normal, but the passage of the 
 sound gave great pain. The displacement was easily reduced, 
 and then it was found that both ovaries were very much en- 
 larged and tender, the left especially. They could both be dis- 
 tinguished by bimanual touch as quite free from adhesion, 
 readily moving about. I introduced a ring-pessary to rectify 
 the displacement, much to her comfort, and directed the use of 
 iodine-paint in the manner previously described. She also took 
 a tonic mixture consisting of cinchona and angostura, and the 
 uterine cavity was occasionally washed out with a weak solution 
 of neutral acetate of lead. The latter part of the treatment was 
 discontinued after a few months, but the counter-irritation and 
 the pessary were persevered in, along with occasional recourse 
 to tonics. In October, 1875, the brown discharge had almost dis- 
 appeared, and the right ovary could be felt to have distinctly 
 diminished in size. The uterus was also straight and the cervix 
 closed, and the whole organ of a much less size. Early in No- 
 vember there was a slight menstruation lasting three days, and 
 in January of this year there occurred quite a normal period of 
 four days, followed by rather profuse leucorrhoea. In February, 
 as the expected period did not occur, I ordered her small doses of
 
 124 DISEASES OF THE OVARIES. 
 
 iron, in the form of ten drops of Parrish's syrup of the phos- 
 phates, taken thrice daily. 
 
 For the last five years the treatment has been varied, both by 
 myself and others, but nothing seemed to have any very marked 
 -effect, unless it be residence at Kreuznach and the prolonged 
 use of the waters. Nature seems to be working her own cure, 
 and the only question to be discussed is: Would it not be better, 
 in such ci case as this, to run a slight risk in the removal of the 
 ovaries, and so effect a speedy and permanent cure 'i I think it 
 would, and so does my patient. 
 
 There is probably a chronic ovaritis of occasional occurrence 
 in chronic phthisis; for, though the rule in that disease is to have 
 ovarian atrophy, evinced first in dysmenorrhoea and finally in 
 amenorrhoea, yet I have seen a few cases where the menstrua- 
 tion was jDrofuse, irregular, and characterized by the other 
 symptoms of chronic ovaritis. I have seen such conditions tem- 
 porarily after small-pox, and frequently after scarlet fever in 
 adolescent women. One case I have also satisfied myself of in 
 early acquired syphilis. There is a distinct form of syphilitic 
 metritis, as pointed out long ago by Mr. Langston Parker, and 
 no doubt in these cases the ovaries are involved. 
 
 Arthur Farre has noticed an intense red coloring of the ova- 
 ries in cardiac disease, and I have more than once found that in- 
 tractable menorrhagia had apparently its origin in valvular dis- 
 ease of the heart, or at least was closely associated with it, in 
 such cases there being often no discoverable lesion of either ute- 
 rus or ovaries. 
 
 I have met with a small group of cases which I can only class 
 under the head of ovarian neuralgia. Tliey have been charac- 
 terized by acute lancinating pain referred to the region of the 
 ovaries, generally on both sides, coming on paroxysmally, with- 
 out any reference to the uterine or ovarian functions. No physi- 
 cal signs of disease have been found in these cases, and the}^ have 
 all occurred in women approaching the menopause. They have 
 all been addicted to outbursts of over-indulgence in drink, taken, 
 as they allege, to deaden the pain. Whether this inebriety was 
 a cause or a result of the neuralgia, or whether the neuralgia in 
 some of the cases may have had any actual existence, I am un- 
 able to say; though the special character of the pain and its site 
 have been described by the sufferers with a constancy which 
 would seem to vouch for its reality. In connection with this 
 affection I would here urge the necessity for the medical pro- 
 fession combating strongly against the wi'ong wonieu are often 
 allowed to do themselves by taking spirits to relieve ovarian 
 iind menstrual pain. No habit can be more pernicious, or more
 
 OOPHORITIS AND PERI- OOPHORITIS — ABSCESS OF OVARY. 125 
 
 likely to lead to the most deadly mischief, both physical and 
 moral. 
 
 A singular condition has been noticed by Dr. Priestley, of 
 intermenstrual pain, occurring about midway between the peri- 
 ods, wliicli is almost certainly due to an ovarian condition, 
 though it is not clear of what kind. Since reading his paper I 
 have seen several cases, but have been unable to refer them to 
 any category. 
 
 Abscess of the ovary is a condition of extreme rarity, or. at 
 least, it certainly is one which we can rarely diagnose during 
 life, and in the majority of instances probably death occurs from 
 the rupture of the abscess into the peritoneum, without any di- 
 agnosis having been made beyond that comprised in the generic 
 term of an attack of '• inflammation of the bowels," under whicli 
 category a large number of cases are entered in the death regis- 
 ter, many of which probably might have been relieved if a more 
 accurate diagnosis had been possible. Of the cases of abscesses- 
 of the ovary which recover after rupture we of course only find 
 subsequent traces in the indications of old perimetritis which are? 
 usual after a great many other lesions as well as this. Probably, 
 however, the larger number of cases which have been published 
 as abscesses of the ovary are nothing more than suppuration in 
 ovarian cysts, and therefore belong to an altogether different 
 category from those of wliich I am now speaking. 
 
 True abscess of the ovary is said to occur most frequently in 
 connection with pelvic suppuration of the puerperal woman, and 
 possibly this may be a condition of pretty frequent occurrence. 
 I have, however, for many years past, carefully avoided attend- 
 ing post-mortem examinations of such cases, and therefore I 
 have seen no instance of this kind. The only cases of abscess of 
 the ovary, in clinical experience, of Mdiich I have been certain, 
 are two, one of which I have already narrated under the head of 
 pyosalpinx; and the second is one of great interest because it 
 also shows what immense success has been recently made possi- 
 ble by the advances of abdominal surgery. 
 
 The patient was sent to me by Dr. Lycett, of Wolverhampton, 
 and I cannot do better than give the history of the case, which 
 he sent to me in a letter, as being quite a model of what such 
 communications should be. It was as follows: 
 
 " She is about thirty-eight years of age. and has suffered for 
 many years from great ovarian pains, rarely free, and much in- 
 creased at the menstrual period, which are often fortnightly, 
 scanty, and prolonged for a week or ten days. The left ovary 
 seems the one at fault, being tender and somewhat enlarged; 
 the uterus is rather conical, but the passage fairly patent. She
 
 126 DISEASES OF THE OVAEIES. 
 
 lias had a variety of treatment under my hands, and, though able 
 to afford some relief, yet I see no prospect of permanent good, 
 so that at last I am desirous of your opinion as to oophorectomy, 
 for her health has materially suffered, as you will observe. She 
 is a weakly, nervous, anaemic person, whose life is a misery, and 
 may probably break down before the menopause. She has not 
 had any children. Several times at the periods her temperature 
 has risen to even 102°, marking some local inflammation, and at 
 these times the pain and tenderness is greater." 
 
 No history could be more graphic, concise, and complete. 
 The only additions I can make to it are that marital life was ab- 
 solutely unendurable, and that I found the left ovary adherent 
 in the cul-de-sac. 
 
 I quite concurred with Dr. Lycett's views, and with his con- 
 currence and assistance I performed ovariotomy on June 28th. 
 I found the left ovary firmly adherent in front of the rectum, 
 and to pull it off from its attachment was a work of difficulty. 
 It contained about two drachms of pus, and appeared to be just 
 on the point of bursting into the peritoneal cavity. Had it so 
 burst, she doubtless would have had an attack of acute peritoni- 
 tis, from which she might have died. The right ovary was shriv- 
 elled, so I removed that also. She made a perfect recovery, and 
 not only is cured, but her sexual relations are now possible, 
 so that not only has removal of the ovaries not unsexed her, 
 but it positively has resexed her — a statement which I have 
 made about a number of other cases of a somewhat similar 
 kind. 
 
 Two cases of abscess in both ovaries, narrated by Mr. C. J. 
 Cullingworth, in the Lancet of November 3, 1877, illustrate well 
 this unusual disease, and are equally instructive in showing the 
 disastrous results of delay in the performance of abdominal sec- 
 tion in cases of doubt, where patients are suffering from pelvic 
 mischief. 
 
 The first was a case of a woman, aged forty-five, admitted on 
 January loth, with vomiting, severe pain in and enlargement of 
 the abdomen. In the lower part of the abdomen was a fluctua- 
 ting swelling, reaching nearly as high as the umbilicus, quite 
 dull on percussion, and a soft, rounded swelling in the vagina, 
 to the right of the uterus. The morning temperature was low 
 and the night temperature high, showing clearly the presence of 
 pus, as did all the symptoms. 
 
 "January 27th. — Thirty-five ounces of pus were withdrawn 
 by the aspirator, without relief. 
 
 "February 7th. — An exploratory incision was made, and a
 
 OOPHORITIS AIS^D PERI-OOniORITIS — ABSCESS OF OVARY. 127 
 
 large abscess opened in the abdominal walls, outside the perito- 
 neum, with a communication into the abdominal cavity. The 
 patient died a few hours after the operation, and the post-mortem 
 displayed that the source of the mischief was an abscess in the 
 right ovary, which had burst. The left ovary also had become 
 converted into a small bag of purulent fluid." The case seems to 
 have had a very chronic progress, and if the abdominal section 
 had been done some weeks before it was, there probably would 
 have been a successful result. 
 
 The second case is an even more instructive one. About the 
 middle of 1875 she noticed an enlargement of the abdomen, and 
 was suffering from local distress. In June, 1876, this amounted 
 to constant pain in the left iliac region, where there was a dis- 
 tinct, hard swelling, tender on pressure. The uterus was quite 
 hard, the vagina was encroached upon, and its upper part ex- 
 quisitely tender to the slightest touch, causing great suffering. 
 An exploratory puncture was made without result, and after 
 some months' residence in the hospital she was discharged on 
 March 31, 1877. 
 
 She was readmitted in May following, with the symptoms 
 much aggravated, the abdomen uniformly enlarged and univer- 
 sally tender, and the old, tender swelling could still be felt. The 
 night temperature was always considerably higher than that of 
 the morning. She was kept under observation till August 3d, 
 when she died. 
 
 The post-mortem examination revealed old peritonitis. The 
 right ovary was four and three-fourths inches in its large cir- 
 cumference, and three and one-fourth in its shorter, and was a 
 mere shell, filled with offensive, purulent fluid. The left ovary 
 was much larger, and formed the large tumor which was felt 
 during life, and this again was filled with a highly offensive, 
 purulent fluid. 
 
 In such a case as this it is impossible to resist the conclusion 
 that abdominal section, performed soon after the onset of the se- 
 rious symptoms, would have enabled the surgeon to have re- 
 lieved his patient. 
 
 M. C. Darolles contributes some valuable observations con- 
 cerning the microscopic examination of ovaries, in which ovaritis 
 had resulted in the formation of abscess. He found that the 
 process began in the suppuration of separate follicles, and that 
 these subsequently coalesced, forming abscess of the whole gland. 
 Such cases, he points out, as well as those of suppurative inflam- 
 mation of the tubes, frequently result in a series of secondary
 
 128 DISEASES OF THE OVARIES. 
 
 accidents, such as pelvi-peritonitis and acute general peritonitis, 
 which may have a rapidly fatal issue. 
 
 M, C. Salanion has narrated a series of cases of tubercle of 
 the ovary ; but, as this condition is always associated with tuber- 
 cle elsewhere, which is of far greater consequence, it can be 
 regarded only as having an interest of curiosity. I have not 
 heard of a case of tubercle of the ovary only. 
 
 Hermaphroditism. — If the law of evolution embraces all or- 
 ganized structures — and its details have now been so fully 
 Avorked out that we may assume that it does — we must accept 
 Darwin's theory of the descent of man. This acceptance at once 
 becomes the explanation of the occasional occurrence of bisexual 
 vertebrates, and consequently of true hermaphroditism in human 
 individuals. Conversely, the occurrence of such malformations 
 may be offered as one among the many proofs which are being 
 accumulated from every quarter in favor of Darwin's theory, for 
 they must be regarded as reversions of type. In the vegetable 
 kingdom the majority of the species are bisexual, though modern 
 investigations have shown most ingenious contrivances to secure 
 the advantages of cross-fertilization.' Even in the more com- 
 plex organisms of the animal kingdom, bisexuality is met with 
 as high up as the nudibranchiata, while in the next sub-order, 
 the prosobranchiata, most of the groups are unisexual. In the 
 cephalopoda, where other great advances in structure are indi- 
 cated, unisexuality is the rule. From this point a symmetrically 
 double body is introduced into the scjiema, though it is met with 
 also in the insecta, and the sexual organs are double, one in 
 each half of the body. But as in the insecta, where unisexuality 
 is the rule, hermaphroditism occurs with some frequency, so it 
 does in the lower vertebrates, the frequency of the malforma- 
 tion diminishing, until in man true hermaphroditism is found 
 very rarely. In all cases of hermaphroditism in animals where 
 unisexuality of the individuals is the rule, the doubly sexed 
 organs are always imperfect, even in insects ; and in most of the 
 cases recorded in birds there has been on the male side only a 
 convoluted seminal tube and no testicle, so that the tube might 
 have been taken for an aborted oviduct, had it not been, as in 
 one of Simpson's cases (" Encyclopaedia of Anatomy and Physi- 
 ology "), for the coincident presence of the characteristic epithe- 
 lial appendages of the male. In Simpson's second case I do not 
 think there was any evidence of true hermaphroditism. 
 
 ' See Darwin's "Fertilisation of Orchids," "Cross and Self -Fertilisation of Flowers," 
 and Kemer's '' Flowers and their Unbidden Guests."
 
 OOPHORITIS AT^D PERI-OOPHORITIS — AB.=?CESS OF OVARY. 129 
 
 The human testicle and ovary being developed from the same 
 blastema, and being really the same organ, it is not surprising 
 that occasionally reversions of type should occur, so that an im- 
 mature testicle should appear on the one side, and an imperfect 
 ovary on the other. According to Simpson, the ovary in these 
 cases appears generally on the left side. This distinguished 
 author has collected from many sources a large number of cases, 
 the descriptions of some of which are not above suspicion ; but 
 in others, especially that recorded by Dr. Banon in the Dublin 
 Medical Journal for 1852, the facts are beyond dispute; for the 
 examination of the textures of the gland on either side by the 
 microscope completely established that one was an ovary and 
 that the other was a testicle, though both were so immature as 
 to contain no perfect products. There was an imperforate penis, 
 the urethra opening at its root, and behind this a genital canal 
 closed by a perfect crescentic hymen, a fact which at once 
 removes the case from the classes of spurious hermaphrodites 
 already described. This genital canal led up to a small, well- 
 formed uterus with normal relations to the bladder, rectum, and 
 peritoneum, and having at its left cornu a perfect Fallopian 
 tube with a corpus fimbriatum. In relation with this there was 
 an ovary. There was neither tube nor ovary on the right side, 
 but a testicle containing the characteristic tubules, and provided 
 with an epidydimis and vas deferens. Simpson calls this \x\iq 
 lateral hermaphroditism ; and he further describes what he calls 
 true transverse hermaphroditism, that is, where the internal 
 organs, testicles, or ovaries, are alike on the two sides, but the 
 external organs represent appearances somewhat like those of 
 the other sex. But it is not clear in any of the cases he quotes 
 that the malformation was anj^thing more than an extension of 
 the characters of spurious hermaphroditism ; and as the glan- 
 dular element must always be considered as the chief element of 
 sex, it is not a philosophical proceeding to say that both sexes 
 are represented unless both a testicle and an ovary are present. 
 Even when the clitoris is perforated by a urethra as far as the 
 glans, the condition is only that seen normally in the Loris 
 gracilis. 
 
 This view, which I first enunciated in 1873, has been most 
 fully confirmed by an admirable paper by Prof. Morrison Wat- 
 son, in the Journal of Anatomy, October, 1879. He says : '"In 
 the gland alone and its structure is to be found the determina- 
 tion of sex. No arrangement of the passage is absolutely dis- 
 tinctive. Even the prostate gland is absent in the males of some 
 animals (elk, red deer, etc.), and it is occasionally present in 
 many female mammals, even women. The lateral hermaphro- 
 9
 
 130 DISEASES OF THE OVARIES. 
 
 dites of Simpson are those to whom alone the term time can be 
 applied." 
 
 In Simpson's third variety, to which he gives the name of 
 '•'true double or vertical hermaphroditism," he describes the 
 presence of a gland of each sex as present on both sides, or, as 
 he says, "actual sexual duplicity." Without denying the possi- 
 bility of such an occurrence, I must say that I think it very un- 
 likely, and I have no hesitation in saying that none of the cases 
 he quotes justifies the establishment of this variety. The most 
 complete case is that recorded by Vrolik, and he distinctly states 
 that neither in the structure which he supposed to be testicle nor 
 in that considered to be ovary did he find a trace of histological 
 evidence of the nature of the gland. Mere anatomical position 
 goes for nothing in such a case, for the ovary descends some- 
 times in the same way as does the testicle, for it also has a 
 gubernaculum. It must also be borne in mind that occasionally 
 appendices both to testicle and ovary are met with, giving the 
 appearance as if the individual had three or even four testicles 
 or ovaries. If such a condition were met with in a hypospadic 
 male who had at the same time an enlarged prostatic utriculus, 
 as many of the cases quoted by Simpson undoubtedly had, and 
 if the testicular appendix had not descended with the true testicle, 
 the appearances would be exactly as described in most of Simp- 
 son's cases, and yet there would be not the slightest reason for 
 the statement that both kinds of glands were present. The only 
 satisfactory test is that of microscopic examination; and so far 
 the evidence goes to show that there is only one kind of true 
 hermaphroditism— that in which there is an ovary on the one side 
 and a testicle on the other. 
 
 The cases lately recorded by Leopold, of Leipsic, and C. E. 
 Underbill, of Edinburgh, are clearly cases of descent of undevel- 
 oped ovaries into the inguinal canal — instances of hypererchesis.
 
 CHAPTER IV. 
 
 OVARIAN TUMORS AND CONDITIONS WHICH SIMULATE THEM. 
 
 BUlroth's Handbuch der Frauenkrankheiten. Heft VI. R. Olshausen. Stuttgart, 
 
 1877. 
 Clinical Lectures. Mathews Dcncan. London, 1879. 
 Gooch on Diseases of Women. Fekgu asoN. London, 1859. 
 Kystes de I'ovaire. Gallez. Bruxelles, 1873. 
 Ovarian Tumours. Peaslek. London, 1873. 
 Diseases of the Abdomen. Edw.\rd Ballard. London, 1833. 
 Ovarian Physiology and Pathology. Ritchie. London, 1865. 
 Lessons in Gynecology. Goodell. Philadelphia, 1880. 
 Females and their Diseases. Meigs. Philadelphia, 1848. 
 Ovarian Tumors. Atlee. Philadelphia, 1873. 
 Ovarian Dropsy. Baker Brown. London, 1868. 
 Tumours of the Uterus. T. S. Lee. London, 1847. 
 Entwickelang der Ovariencysten. Staiil. Cent. f. Gyn., V., T. 
 .iEtiologie der Ovariencysten. Breisky. Cent. f. Gyn., V., I. 
 Ovariencarcinom. Ullac. Cent. f. Gyn., V., I. 
 Myxoid Krebs der Ovarien. Mosse. Cent. f. Gyn., V., I. 
 Ovarienschwangerschaft (Spiegelberg). Gurchard. Cent. f. Gyn., V., I, 
 Grossesse de I'ovaire. PuECn. Ann. de Gyn., July, 1878. 
 Ovarienadenom. Neelsen. Cent. f. Gyn., V., IIL 
 Eierstocksarcomen. Leopold. Arch. f. Gyn., V., XTII. 
 
 Ueber Blutergiisse u. Blutgeschwulste der Ovarien. Leopold. Arch. f. G., V. ,XIII. 
 Ovarium Tumor mit elweissfreien Inhalte. Westphal. Schmidt's Jahrbuch, V. 169. 
 Ovarium Cystenadenosarkom. Schmidt. V. 174. 
 Ovarialschwangerschaft. SCHMIEDT. Schmidt. V. 178. 
 
 Carcinom der Ovarien. Kuster u. Kegscheider. Beitriige f. Geburt. V. 4. 
 Ueber Dermoid-Cysten des Ovariums. Pauly. B. f. Geb. V. 4. 
 Ovarialschwangerschaft. Besuche. Berlin, 1876. 
 Histologic der Ovarientumoren. M.\RCHAND. Cent. f. Chir. V. 4. 
 Cavernoses Fibrom des linken Ovarium. Dannier. Arch. f. Chir. V. 21. 
 Ein Fall von Psammocarcinom des Ovarium. Flaischlen. Virchow's Arch. , Jan., 
 
 1880. 
 Des Tumeurs solides de I'ovaire. Liembecki. Arch, de Gyn., 1877. 
 Ovarian Cysts in Infants. Leared. Lancet, 1878, YI. 
 Fibroma of the Ovaries. Goodhart. Med. T. andGaz., 1874. 
 Ovarian Cyst with Muscular Envelope. 6. Hewitt, Patholog. Soc. Trans., 1874. 
 Pathology of the Ovaries. M. Duncan. Med. T. and Gaz., 1875. 
 Dermoid Tumours of the Ovaries. Med. T. and Gaz.. 1877. 
 Tumours of the Ovary in the Pheasant. Slater. J. Anat. and Phys., 1879.
 
 132 DISEASES OF THE OVARIES. 
 
 Kystes de I'ovaire. Sinety and Melassez. Arch, de Phys., 1873. 
 
 Ovarian Serous Cysta. Panas. Amer. J. Obstet., May, 1875. 
 
 Ovarian and Parovarian Cysts. Koeberle. Obstet. Journ. V. 4. 
 
 Cancer of Ovary, Foui.is. Ed. Med. Jour.. 1874-75. 
 
 Pathology of Unilocular Ovarian Cysts. Bantock. 
 
 Suppurating- Ovarian Cysts. Keith. Edin. Med. Journal. 
 
 Torsion of Pedicle of Ovary. Koeberle. Amer. Med. J. Obstet., 1878. 
 
 Axial Rotation of Ovarian Tumours. Lawson Tait. Trans. Obstet. Soc. Lond. Vol. 
 
 XXII. 
 Maladies des Ovaires. Botnet. Arch. Generales. 1874. 
 Cancer of Ovaries Transplanted. Goodttart. Pathol. Trans., 1874. 
 Fibro cystic Disease of Ovaries. Legg. Pathol. Trans., 1874. 
 Fibroma of Ovaries. Goodhart. Pathol. Trans., 1874. 
 Fibroma of Ovaries. Walsham. Pathol Trans., 1876. 
 Fibroid Ovaries. Crisp. Pathol. .Trans., 1877. 
 Lymphadenoraa of Ovaries. CouPLAND. Pathol. Trans , 1877. 
 Intra-ovarian Pregnancy. Talbot. Med. Record, 1879. 
 Ovarian Pregnancy. Med. Record, 1874. 
 Extra-Uterine Gestation of the Tubo-Ovarian Form. Dr. Sibley Campbell. Amer. 
 
 Jour. Obstet., Vol. 187G. 
 Eierstocksschwangerschaft. Leopold Landau. Arihiv. f. Gynakologie, Bd. XVI. 
 P ipilloma of Ovary. Emmet. New York Med. Journal, 1879. 
 Diagnosis of Ovarian Tumors. Boston Med. J., 1879. 
 Zur normalen und pathologischen Histologie des Graaf'schen Bliischens des Menschen. 
 
 SwiANSKi. Virchow's Arch. V. 51. 
 Rokitansky's Pathological Anatomy. Sydenham Society. 
 
 Pathologische Anatomic der weiblichen Sexual -Organe. Klob. Vienna, 1864. 
 Beobachtungen iiber die Entwickelung multilocularen Eierstockcysten. Boettciier. 
 
 Virchow's Archives. V. XLIX. 
 On Cystic Tumours of the Ovary. Wilson Fox. Trans, Roy. Med.-Chir. Soc, 18G4. 
 
 Ovarian pathology has always been a fertile field for re- 
 search, and although the list of writers upon this subject which 
 I have given above is a long one, it by no means fully represents 
 the great number of contributions which have been given to it. 
 The interest which diseases of these organs has always excited 
 has been greatly increased during the last twenty years, owing 
 to the remarkable triumphs which surgery has achieved in the 
 establishment of ovariotomy as the most successful of the major 
 operations. 
 
 The pathology of ovarian tumors — especially tliose of a cystic 
 character — involves a number of questions which have been 
 raised and discussed by observers of the greatest eminence; but 
 I think it is only in very recent times that anything like a rea- 
 sonable view of the origin of these growths has been advanced. 
 In the first edition of this book I said that, up to the time of my 
 writing it, I had found very little which either harmonized with 
 my own observations, or seemed to me to give any satisfactory 
 explanation of these growths. The conclusions which I put for- 
 ward were at variance with those held by many previous and
 
 OVAEIAN" TUMORS, CONDITIONS WHICH SIMULATE THEM. 133 
 
 probably much more competent observers; but these conclusions 
 nevertheless seemed to me to be founded on fact, and to have 
 the strong recommendation of affording explanations which 
 were at least simple and intelligible. Since I wrote this a good 
 deal mo*"e has appeared on the subject, much of which I have 
 carefully studied, but without finding reason to depart from the 
 views I published in 1873. 
 
 What seem to me by far the most important contributions 
 recently made to ovarian pathology are the papers published by 
 MM. De Sinety and Melassez, in the Archives de Physiologie for 
 1878. I find in these papers a great deal which completely con- 
 firms my own previous conclusions; but, on the other hand, it is 
 equally fair to say that much which has been advanced by these 
 authors is quite out of harmony with what I have myself ob- 
 served. Upon the latter point, however, I think the facts estab- 
 lished by Balfour, in his researches upon the development of the 
 ovary, which have been given at length in a preceding chapter, 
 may be taken as conclusive, more particularly upon the alleged 
 development of cystic disease of the ovary from the so-called 
 tubes of Pfliiger. 
 
 As to the prime causes which lead to any of these diseases, 
 we may at once confess ourselves to be profoundly ignorant, and 
 what little we do know is entirely confined to the processes by 
 which these causes produce their peculiar results. It may be 
 that some day we shall know here, as we desire so much to know 
 in every other field of pathological inquiry, what may be the ul- 
 timate causes of any particular lesion; but up to the present we 
 have no instance of any knowledge of this kind. 
 
 It is extremely difficult to arrange the discussion of this sub- 
 ject in such an order as will be satisfactory from a general view, 
 and any division of ovarian tumors must be entirely arbitrary. 
 We may take the'm from their physical characteristics, or from 
 their surgical peculiarities, or from their microscopic appear- 
 ances, or from their supposed methods of origin, but we cannot 
 possibly take them in an order which will satisfy all these as- 
 pects. De Sinety and Melassez adopt a perfectly arbitrary 
 method of classification, which in itself would not be objection- 
 able were it not that the names they make use of for the pur- 
 poses of their division are such as — in England at least — involve 
 certain meanings which the authors evidently do not imply by 
 them. Thus, they divide their observations into those upon 
 " cystic ovaries," thereby meaning instances where the cysts are 
 very small, and where the ovary is still easily recognizable. 
 "Cysts of the ovary" they use to designate tumors where the 
 ovary is no longer distinct, but seems to have disappeared. And
 
 134 DISEASES OF THE OVARIES. 
 
 then again, when they speak of a case in which the solid parts 
 of a tumor become the predominant elements, they use the term 
 '• cystic tumor," It is perfectly useless to take up space in dis- 
 cussing the want of precision of such a division as this; all that 
 can be said in its favor is that it is no more illogical than others 
 which have been propounded. The authors themselves say: " It 
 is very certain that between cystic ovaries, ovarian cysts, and 
 cystic tumors of the ovary, there exists quite a series of interme- 
 diate tumors, and that it would be very difficult, even impossible, 
 to establish between them well-defined lines of demarcation. In 
 fact, the difficulty is just the same as has been found, within 
 the last two or three years, to hang round the use of the word 
 ovariotomy ; for every one whose experience has extended be- 
 yond the removal of large ovarian cystomata, has found it quite 
 impossible to use any such word as oophorectomy, in contradis- 
 tinction to ovariotomy, without some arbitrary definition and 
 division of his cases. Therefore I have already indicated my 
 intention hereafter to make use of the word ovariotomy to in- 
 clude the removal of an ovary for any purpose or disease what- 
 soever. In like manner I intend the word cystoma to refer to 
 any disease of the ovary in which the existence of cysts is a 
 leading characteristic. Whether I may be more successful than 
 my predecessors in establishing subdivisions of this disease, or 
 whether I may succeed in giving a rational view of their meth- 
 ods of production, must be left to the judgment of my readers. 
 
 In the first chapter of this book I have drawn attention to the 
 somewhat numerous observations which establish the fact that 
 at the time of birth the follicles of the ovary are very frequently 
 found to be so much distended by limpid fluid as almost to pre- 
 sent the appearances of disease; and from the fact, equally well 
 established, that these cysts do rupture and go through the stages 
 of cicatrization, we may assume as proved, that in the dropsical 
 distention of the Graafian follicle we have at least a very com- 
 mon origin of ovarian cystoma. If we go through the literature 
 of this subject, we shall find numerous instances in which these 
 follicles have become so distended as to have an absolutely morbid 
 appearance. Thus, in the American Journal of Obstetrics for 
 January, 1880, Dr. T. G. Thomas describes an ovarian cyst, re- 
 moved post-mortem from a new-born child, which was sent 
 him by a physician in Xew Jersey. The peculiarity in the case 
 was that the child was delivered at full term, and nothing ab- 
 normal was discovered. About one month after birth a tumor 
 was discovered in one iliac fossa, about the size of a hen's egg. 
 The child was well developed at the birth, but soon began to 
 show signs of impaired nutrition, grew very slowly, became
 
 OVARIAN TUMORS, CONDITIONS WHICH SIMULATE THEM. 135 
 
 emaciated, and languished until it was three years and five 
 months old, and then died. The autopsy revealed the existence 
 of an ordinary ovarian (or parovarian ?) cyst filling the abdomen. 
 The remains of the Fallopian tube and ovary were upon one side 
 of the tumor. 
 
 At a meeting of the Pathological Society of London, on May 
 21, 1878, Dr. Leared showed specimens of ovarian cysts from 
 twin infants, who had been under the care of Dr. Macmahon, of 
 Norwood. They were born at full term, and one, jaundiced 
 from birth, died at the age of eight weeks. There v/as found 
 complete obliteration of the common bile-duct. Each ovary was 
 the seat of a cyst the size of a filbert. The other child died from 
 pneumonia, and it also presented a small ovarian cyst the size of 
 a pea. 
 
 The observations of De Sinety and Melassez, and also those of 
 Hausmann, therefore, lead us to the conclusion — which has been 
 quite established by fact — that ovarian cystoma may be the result 
 of these processes in the young child, and that we may expect, 
 every now and then, to see one of these follicular dropsies reach 
 such a size as to require surgical interference. Thus, Dr. Basil, 
 of Bonn, has performed ovariotomy on a child two years of age, 
 on account of a large cystoma. Mr. Folker, of Hanley, has op- 
 erated at three years of age. A case is recorded by some Ameri- 
 can surgeon of an operation at seven, and Mr. Wells has operated 
 on a child of eight years. The probability is that in these cases, 
 and in many others, the cystoma has been due to the extension 
 of the follicular dropsy, which occurs normally during the first 
 three months of life, and which has become pathological by rea- 
 son of the follicles not rupturing, as in the ordinary course of 
 events. 
 
 Waldeyer, in the Arch. f. Gyncekologie, tome I., p. 289, also 
 observes that: "In the ovaries of old women are often found 
 small cysts from the size of a pea. . . . They are covered with a 
 cylindrical epithelium, which, under the form of glandular tubes, 
 often penetrates into the ovarian stroma. . . . These little cysto- 
 mata never contain ovules or remains of ovules. ... In some 
 cases may be seen a continuation of the epithelium which covers 
 these cystic cavities with the epithelium of the ovarian surface." 
 
 Here, then, we have a starting-point, from which we may 
 arrive at an explanation of ovarian cystoma — the only one, in 
 my belief, that can be reasonably advanced. It seems to me it 
 will explain all the specimens which I myself have examined. 
 Indeed, I am quite strengthened by my later researches, as well 
 as by those before referred to, in the views I advanced eight 
 years ago, to the effect that ovarian cystoma is the result of fol-
 
 136 DISEASES OF THE OVARIES. 
 
 licular dropsy only. The fact which is now almost universally 
 admitted, that ovarian cystomata are never unilocular, also 
 points to this conclusion. Thus, De Sinety and Melassez say: 
 "Amongst all the cysts we have examined, we have not found 
 one which was truly unilocular. All those sent to us as such 
 presented, truly, a large principal cyst, but, on examining them 
 with care, we have always found other cystic cavities, some- 
 times small enough, it is true, to pass unperceived on a first 
 examination.'' 
 
 This conclusion I can entirely substantiate from the exam- 
 ination of a very large number of tumors. There is one possible 
 exception, however, and that is of a small cyst — now in the mu- 
 seum of the College of Surgeons — which I removed as an ovary, 
 in a case of severe hemorrhage due to a uterine myoma. The 
 patient recovered, and the operation had for some months a per- 
 fectly successful result; but about seven months after it she died, 
 as I believe, from cancer of the uterus. No post-mortem exam- 
 ination was made, and I have been quite unable to obtain any 
 information concerning her case from the practitioner under 
 whose care she was at the time of her death. It is, therefore 
 quite possible that what I removed on that side was not the 
 ovary; or, it may be that I did not remove the whole of the 
 ovary, but merely an outstanding cyst. At any rate, I do. not 
 feel disposed, on account of this isolated and incomplete obser- 
 vation, to depart from the conclusion I have come to from an 
 otherwise uniform experience, which is that such a thing as a 
 unilocular ovarian cystoma does not occur. On a priori grounds 
 such a condition would be extremely unlikely, for it is difficult to 
 imagine — whatever be the cause of the distention of Graafian 
 follicles into pathological cysts — that it could or would affect one 
 follicle only, and allow the rest of the gland to remain free from 
 its influence. Conversely, granting the likelihood that follicular 
 dropsy develops ovarian cystoma, then we have at once an ex- 
 planation of what is the fact — that these tumors are always mul- 
 tilocular. 
 
 I think that the term adenoid may be retained with advan- 
 tage in the nomenclature of ovarian tumors, because it con- 
 veniently classes them with reference to the tissue from which 
 they originate, and by the hyperplasia of which they are formed, 
 without giving any theoretical explanation of their formation. 
 All non-cancerous tumors of the ovary are, therefore, adenoid; 
 even the dermoid tumors are so to a certain extent, for they are 
 the result of increased growth of one or other normal constituent 
 of the gland, without alteration save in quantity. Cancerous 
 growths, on the other hand, introduce tissue which is either not
 
 OVARIAIS' TUMORS, CON^DITIOiSrS WHICH SIMULATE THEM. 137 
 
 found in the gland normally, or they produce it in a form which 
 is immature. 
 
 There are two methods of origin for pathological cysts which 
 are universally accepted, and both of which are instanced in the 
 ovary. The first is by occlusion of normal ducts or tubes, as best 
 seen, perhaps, in the kidney and salivary glands, and in connec- 
 tion with the ovary in the form of cystic dilatation of the Fallo- 
 pian tube or of its trumpet-shaped extremity, after adhesion to 
 the ovary — tubal and tubo-ovarian cysts. The other form of 
 cyst-growth consists in the dilatation of a physiological cyst- 
 cavity by its own secretion poured out to an abnormal extent; 
 and this secretion may either retain its original character and 
 constitution, or be altered by the addition of blood or of some of 
 its usual or exceptional albuminous products. This is the com- 
 mon form of cyst-formation in the ovary, and in the multiple 
 adenoid tumor and in the dermoid we see instances of it. The 
 former illustrates the formation of cysts by the retention of its 
 products in the cavity of the normal sac of the gland, these pro- 
 ducts being the fluid cell-substance and its nucleus, the ovum. 
 This is accomplished, as far as I could discover from two speci- 
 mens I -have to describe, by hypertrophy of the fibrous covering 
 of the gland — a sclerosis of the ovary ; and the nucleus, the 
 ovum, seems to have retained its normal appearance until de- 
 stroyed by some process not yet understood. It is, however, 
 possible that some defect of action in the nucleus may have to 
 do with the non-rupture of the sac; for, under healthy conditions, 
 it is undoubtedly the maturation of this nucleus that governs the 
 rupture of the wall of the ovisac, and enables the perfect ovum 
 to escape. Upon this point it seems to me that the observa- 
 tions of De Sinety and Melassez have very great value, for they 
 show that, coincident with the absence of the ovum in the follicle, 
 changes are effected in the epithelium of a very marked kind. 
 Whether they result from or are themselves the cause of absence 
 of the ovum, we cannot say. 
 
 The dermoid cysts are due, on the other hand, to an altered 
 and increased activity of the cell-nucleus in early life, the results 
 remaining latent for years, until re-excited by the great systemic 
 change. We may look, then, to some other altered condition of 
 the cell-elements for explanation of the remaining variety of 
 cystic tumor of the ovary which has been termed by Mr. Wells 
 and others " proliferous." 
 
 I do not like this term as applied to the compound cysts of any 
 kind, for it assumes, what I am quite certain is not true, that the 
 large cysts are directly the parent of the small ones. Thus, Mr. 
 Wells, at page 25 of his book on " Diseases of the Ovaries," de-
 
 138 DISEASES OF THE OVARIES. 
 
 fines: "Proliferous cysts — parent-cysts with secondary cysts 
 growing from the interior of the cyst-wall." These minor cysts 
 are secondary, as far as date of growth is concerned; but they 
 are the younger brothers and sisters, not the children, of the 
 larger sacs. In fact, the very caution which Paget gave his 
 hearers in using the term proliferous is disregarded in such an 
 application of it, as may be seen from the following quotation : 
 
 "In an ovary, it is not unfrequent to find many small cysts, 
 formed apparently by the coincident enlargement of separate 
 Graafian vesicles. These lie close and mutually compressed, 
 and, as they all enlarge together, and sometimes, by the wast- 
 ing of their partition-walls, come into communication, they may 
 at length look like a single many-chambered cyst, having its one 
 proper wall formed by the extended fibrous covering of the 
 ovary. Many multilocular cysts, as they are named, are only 
 groups of close-packed single cysts; though, when examined in 
 late periods of their growth, and especially when one of the 
 groups of cysts enlarges much more than the rest, it may be 
 difficult to distinguish them from some of the proliferous cysts." 
 (Paget's "Surgical Pathology," p. 415.) 
 
 The formation of a compound cystic tumor in the* ovary, 
 whether it be of the multiple variety or of the less complete kind 
 of which I am about to speak, may be very well illustrated by 
 blowing soap-bubbles in a basin. If the fluid be not viscid 
 enough to enable the bells to retain their form, then the normal 
 condition of the ovary is represented, its cells bursting and dis- 
 appearing. Let us suppose that the cell-growth is constantly 
 going on, and that some alteration occurs in the state of matters 
 which prevents the cell-walls bursting; the fluid in the basin is 
 so viscid that the bells do not break, and bubble after bubble is 
 formed, some larger, some smaller, until a large multicystic 
 tumor is the result. The actual appearances of the cystic ovary 
 may be very well imitated in the basin of soap-lees. A large 
 cyst can be made with little ones crowding into it, looking like 
 its offspring, and the walls between two or three may be broken 
 down, making one larger multilocular — the remains of the inter- 
 vening walls not being left in the instance of the soap-bubbles. 
 If they had been left, the appearances would be identical with 
 Avhat is represented diagrammatically for ovarian tumors in Mr. 
 Wells's book on page 39. In the ovary we have the continual 
 production of cells, representing the continuous blowing of the 
 bubbles; and we have only to discover what it is that is analo- 
 gous in the ovary to the increased viscidity in the solution of 
 soap ; what it is that keeps the cysts in their entirety, pervert- 
 ing a physiological into a pathological process.
 
 OVAEIAX TUMORS, CONDITIONS WHICH SIMULATE THEM. 13D 
 
 With the exception of two examples of " Rokitansky's tu- 
 mor" (to which I give the name of multiple cystoma), and 
 which I shall afterward describe at length, I have failed to find 
 anything like ova in any cysts of the tumors I have examined ; 
 and I have not seen any reason to believe that the little second- 
 ary cysts met with in the walls of some of the larger sacs are 
 what Dr. Ritchie has interpreted them to be — dropsy of the blas- 
 todermic vesicles — chiefly because I have failed to see round 
 them anything like remains of the membrana granulosa, and I 
 have seen three or four of them on more than one occasion on 
 the wall of the same sac. In searching for ova in the cysts of 
 the two tumors where I found them, I had seldom occasion to 
 look for them in the walls of the cysts, as they seemed to have 
 been floating about loose, or to have been set free by the opening 
 of the sacs. In other cases, not finding them in the liquor fol- 
 liculi, I adopted the further plan of first isolating the cyst to be 
 examined, and, having opened it, I searched carefully in every 
 sediment of its contents for the ovum. Not finding it, I turned 
 the sac inside out over a ball of cotton-wool soaked in glycerine, 
 smeared its everted surface with the same substance, and, cover-* 
 ing it piecemeal with a thin glass, I carefully examined it over 
 its whole extent by reflected light. I never found anything I 
 thought was an ovum. In one tumor which I removed lately, I 
 found a mass of secondary growth in the position of the ovary at 
 the base of a single large cyst. I made sections of this mass by 
 the freezing process, and found it composed of follicles all lined 
 with their proper epithelium and undergoing cystic enlargement, 
 but in none was there any trace of an ovum. 
 
 I cannot reconcile this discrepancy between my observations 
 and those of Dr. Ritchie otherwise than by supposing that, hav- 
 ing been one of the discoverers of ova in a certain kind of ovarian 
 tumor, he was too anxious to apply his principle of explanation 
 to all; or he must have had a plan of examination more success- 
 ful than mine. 
 
 My original observations, made in 1872, have been amply 
 confirmed by De Sinety and Melassez, who say: " no author has 
 met with ovules in cysts larger than a walnut. All the large 
 cysts we have studied, and which we shall describe farther on, 
 possessed an epithelial investment completely different from 
 that of the follicles, a fact equally attested by all recent observ- 
 ers." Rindfleisch has found, only once, one ovule in an ovarian 
 cyst of which the cavity w^as no larger than a cherry. 
 
 The fact that I never found ova in any of the sacs of these mul- 
 ticystic tumors, even the smallest, or in those with the most lim- 
 pid contents, led me to entertain the opinion that in this we have
 
 140 DISEASES OF THE OVAKIES. 
 
 an explanation of their formation. The function of the ovary is 
 one of cyst-formation from its earliest existence to its latest, and 
 in its pathology we need not go far away from its physiology. 
 It seems to me, therefore, a priori, very unnecessary to resort 
 to the ingenious explanations of cyst-formation advanced by 
 Dr. Wilson Fox, though they may be fitted to exceptional cases. 
 Experience in the examination of the growths themselves has 
 strengthened this view; for my wonder is greater, the more I sec 
 of them, that they do not occur more commonly and with more 
 complexity than they do, considering the apparently reckless 
 amount of ovarian cyst-production that goes on throughout life. 
 
 The aim and object of this cyst-formation is the production, 
 maturation, and discharge of the ovum. But, if the ovum be not 
 formed, or if it be produced only to a rudimental extent, may it 
 not happen that the cyst will not be ruptured, but go on aim- 
 lessly expanding ? Whatever be the source of tlie change, we 
 know that it does not affect one ovisac alone, but may influ- 
 ence them in great numbers, whether it be in a tumor where 
 the ova have been matured and subsequently prevented from 
 .escaping by sclerosis of the coat of the ovisac, or in a growth 
 where the ova are not to be found. There is a great clinical dif- 
 ference between these two kinds of tumor; for in the one the 
 growth is very limited and slow, and in the other it may be, and 
 often is, extremely rapid, and is practically unlimited in extent. 
 In fact, the growth of these cysts without ova partakes some- 
 what of the character of malignancy assigned to them originally 
 by Bright for clinical reasons. Malignancy, apart from any as- 
 sociation with cancerous structure, is always indicated histologi- 
 cally by a tendency to the production of a form of tissue which 
 is young and immature, and this is certainly the condition of 
 these ovaless ovisacs. 
 
 As a matter of fact, ovarian cystomata are a great deal of- 
 tener malignant than has yet been admitted. The recovery from 
 an ovariotomy is generally so rapid and easy that at the end of 
 a month we say "cured," and discharge the patient. But a num- 
 ber of these "cures" die speedily of cancer of the peritoneum 
 or of other organs, and the more our primary mortality from 
 the operation has diminished, the more numerous have become 
 these secondary deaths from cancer, occurring between three 
 and thirty months after the operation. 
 
 A few months ago I removed an ovarian tumor from a child 
 aged twelve, and did not see, either in the tumor or in the abdo- 
 men, a single trace of malignant disease. She recovered from 
 the operation, but died within the month with cancer in all the 
 large organs. This singular sequence requires explanation, and
 
 OVARIAN TUMORS, CONDITIONS WHICH SIMULATE THEM. 141 
 
 I believe that has now been arrived at, the last link being sup- 
 plied by the work of De Sinety and Melassez ; and if the obser- 
 vations be correct, then a bright light is shed by them on the 
 whole question of cancer. Elsewhere (" Diseases of Women," 
 1877) I have said: "Histologically, the characters of cancer are 
 essentially those of immature and reckless cell-proliferation, the 
 presence of numerous nuclei, both in the cells and free, suggest- 
 ing the idea that they have had no time to become full-grown; 
 and I have never failed to find evidence that the primary changes 
 take place in the epithelium." The bearing of this will be seen 
 more fully later on, when I speak of cancer of the ovary, but at 
 present it leads up to the remarkable discovery of De Sinety and 
 Melassez, to which I have alluded. 
 
 "If, then," say these authors, "we cannot absolutely deny 
 the possibility of the formation of a large cyst of the ovary at 
 the expense of a follicle, it may be seen that this formation does 
 not appear to result from a simple dilatation of these follicles, as 
 many have said, and that we must admit a destruction of the 
 ovules and a transformation of the epithelium when the follicles 
 exceed a certain volume." It will afterwards be seen that there 
 is probably an error in the last clause of this quotation, in that the 
 cause is put for the effect; but it is in the establishment of the fact 
 of the change in the epithelium, or rather in the interpretation of 
 it, that the merit lies. I had long been quite familiar with the fact 
 that between the epithelium of a healthy Graafian follicle and 
 that of a large ovarian cyst there was a great difference. I had 
 also ascertained the fact that, in an ovarian cystoma where 
 ovules were to be found (Rokitansky's tumor, or the multiple 
 cystoma), the epithelium remains as it is in the Graafian follicle. 
 I had concluded, therefore, that the cyst in the latter case was 
 merely the result of follicular dropsy, and that therefore proba- 
 bly all ovarian cysts were the same: but I had not seen, in the 
 alteration of the epithelium, the explanation of the marvellous 
 difference in the two kinds of tumors, nor that here we might 
 find an explanation of the growth of ovarian cystomata. Such, 
 however, I now believe to be the case. 
 
 Among other facts which lead me to the conclusions which I 
 propose now to discuss were the absolute resemblance between 
 the arrangements of the blood-vessels of a Graafian follicle and 
 those of an ovarian cj^stoma which has not been altered by rup- 
 ture, tapping, inflammation, or malignant degeneration. If such 
 a cyst be carefully injected, cut into sections, and compared, in 
 the matter of its vascular arrangements, with a Graafian folli- 
 cle either before or after its rupture, no difference can be seen. 
 The description of these will be seen in the first chapter. Roki-
 
 142 DISEASES OF THE OVARIES. 
 
 tansky, Cruveilhier, Schroeder, Arthur Farre, and De Sinety all 
 record observations — to which I might add several — of cysts 
 which had clearly been produced in the follicle after its rupture 
 by a continuation and recurrence of the hemorrhage, and which 
 have been called haematic cysts. 
 
 The theory, therefore, of this method of growths of cystomata, 
 is that there is a reversion to the premoliminal condition of the 
 ovary, so far as the ova of the affected ovisacs are concerned. 
 The whole ovary does not, of course, become simultaneously 
 implicated, and matured ova may still be given off by some ovi- 
 sacs still unaffected and within reach of the Fallopian fimbrise. 
 Impregnation may thus occur from a degenerated ovary, though 
 it is much more likely to occur from the one which remains 
 healthy. 
 
 We have in these facts the reason that these adenoid tumors 
 occur with greatest frequency during menstrual life, if indeed a 
 future experience may not yet show that they do so exclusively. 
 The menstrual congestion and excitement induces a dropsical 
 distention and growth of a cell which would not be so perverted 
 during childhood or senility, when its blood-supply would be 
 sufficient only for passive nutrition. 
 
 The growth of cysts in the walls of the major sacs, appearing 
 sometimes outside and sometimes within in great numbers, de- 
 pends wholly on the relation of the original adenoid tissue to 
 the cyst-wall ; and, as that wall grew primarily in that tissue 
 and surrounded by it, it would be indeed surprising if it did not 
 carry along with it in its expansion some of the cells of the 
 couche ovigene from which it sprang. These displaced cells have 
 in their turn a stimulus for development, prematurely perhaps, 
 on account of the increased haemic activity of their abnormal 
 surroundings, due to the growth of the sac. They also go through 
 the process of dropsical distention, developing no ova, not rup- 
 turing, but becoming secondary cysts— perhaps ultimately to 
 rival, or even to excel that which has preceded them, on which 
 they grew, and of which they have been supposed to be the off- 
 spring. 
 
 Sometimes these intracystic growths line the cavity of the 
 major cyst like an eruption of small-pox. In the case of a tumor 
 which was removed by my colleague, Mr. C. J. Bracey, hundreds 
 of little separate cysts lined the major sac of the tumor, as if the 
 whole adenoid tissue had been spread on the inner surface as the 
 cyst grew, and as if it were degenerating; and I have no doubt 
 that this was really the case, for these little cysts were all Graaf- 
 ian follicles beyond a doubt. 
 
 The great change effected within the Graafian follicles, which
 
 OVAEIAN TUMORS, CONDITION'S WHICH SIMULATE TIIEM. 143 
 
 is doubtless that to which they owe their subsequent development 
 as cysts, lies in the epithelium. To quote the words of the French 
 writers: "The epithelium in these new formations shows every 
 possible variety; but in none, not even those which simulate the 
 Graafian follicles, have we found any epithelium similar to that 
 of the follicles, neither have we ever found any ovules in their 
 interior." But they very carefully point out that this change is 
 by no means effected suddenly, nor is it extended uniformly over 
 the whole surface of the cyst. 
 
 Speaking of the pathogenia of follicular dropsy, they say: 
 
 " In all the cases we have just stated the follicular epithelium 
 was normal in its form as in its dispositions, although it must 
 have been the seat of a certain degree of proliferation, since it 
 covered a larger surface, the volume of the follicle being aug- 
 mented. Tlie ovule could be detected in a tolerably large num- 
 ber of follicles, even in the largest, and it did not appear altered. 
 The lesion appears then to consist in an augmentation of the 
 follicles, and in a greater quantity of follicular liquid. We can- 
 not say whether this liquid is or is not modified in composition, 
 if the secretion is or is not altered." 
 
 In those cavities which they regard as pseudo-follicles, that 
 is, resembling in every particular save that of their epithelial 
 lining the follicles they have just left, De Sinety and Melassez 
 note that "the differences are still more considerable. The epi- 
 thelium which lines these cavities resembles in nothing that of 
 the follicles. There are found in it cylindrical epithelial cells 
 more or less voluminous, cells with cilia vihratilia, sometimes 
 even caliciform cells. The different kinds of epithelium may be 
 observed in the same cavity. In general these cells are disposed 
 in a single row. 
 
 ' ' In no cavity did we find anything that in any way resem- 
 bled an ovule or a proligerous disc. The contents are a transpar- 
 ent liquid, more or less fluid, coagulating and becoming opaque 
 at the contact of alcohol, reassuming its fluidity and transpar- 
 ency in water, and showing in its interior granulations and 
 degenerated cells, proceeding no doubt from the epithelial in- 
 vestment of the walls. In one of these cavities there existed 
 large, radiated cells disseminated in the contents, which gave it 
 the aspect of mucous tissue." 
 
 The only points concerning the epithelium in which my own 
 observations do not entirely concur with those of the writers I 
 am quoting are, first, the frequency with which they appear to 
 have met with cells furnished with vibratile cilia. I have found 
 these in only one of the tumors I examined, and that was a 
 dermoid cyst, having abundant indications of immature nerve-
 
 144 DISEASES OF THE OVARIES. 
 
 structure; these cells I regarded as probably representing the 
 lining membrane of a cerebral ventricle. Beneke speaks of hav- 
 ing found them once or twice, but I do not know that any other 
 observers have seen them frequently. De Sinety and Melassez 
 speak even of having seen them in a very fresh specimen with 
 the cilia in motion. From the general accuracy of the observa- 
 tions of these gentlemen I am bound to accept these remarkable 
 statements, but I do not see that the occurrence of these cells 
 can be looked upon as having any importance or significance. 
 The second point of difference between us is that in the dropsi- 
 cal follicles containing ova I have found the epithelium quite 
 normal in arrangement and appearance. 
 
 We have, however, from them a complete establishment of 
 the facts that I have so often seen, that we may have in the 
 same ovary — indeed, we may have in the same cyst — indications 
 of a reversion of tji>e in epithelial growth ; that is, we may have 
 the normally cylindrical cells at one part of the lining membrane 
 of a large ovarian cyst, while at another part we may have 
 round, immature, rapidly growing cells, presenting all the ap- 
 pearances they would possess upon a mucous surface. Such 
 cells as these, however, are not seen in a Rokitansky's tumor. 
 In columnar cells the arrangement is, of course, in a layer single, 
 or nearly single, and the first change from the type is seen when 
 we have cells increasing largely in size, becoming somewhat ir- 
 regular in shape, and having underneath another layer polyhe- 
 dral and polymorphous. We may, I think, accept the following 
 description as perfectly accurate: 
 
 •' Sometimes these are flat cells, with sinuous borders, and 
 occasionally of considerable dimensions. Seen in front, in silver 
 preparations, they simulate a pavement with irregular designs, 
 quite different from the very regular mosaic formed by the cylin- 
 drical epithelium. Seen in profile, on sections, their thickness 
 is found to be somewhat variable; it is generally larger on a 
 level with the nucleus. It possesses one and sometimes several 
 nuclei. 
 
 " Sometimes, instead of flat cells, we have thick, voluminous 
 ones, of the most varied and fantastic forms. Some are seen 
 presenting a broad base of implantation, and terminating in a 
 narrow, tapering extremity, which causes them to resemble 
 cones. Others, on the contrary, are only attached to the wall 
 by a thin pedicle, more or less long, while their extremity is dis- 
 tended, which gives them the appearance of clubs. There are 
 some that are broad at the base, broad at their free extremity, 
 and of which the two voluminous extremities are united by a 
 more or less narrow neck. We have seen some which presented
 
 OVARIAlSr TUMORS, CONDITIONS WHICH SIMULATE THEM. 145 
 
 successively two constricted portions, and consequently three 
 distended portions; others which were carried, like grapes, upon 
 a ramified pedicle. The free extremities have a tendency to 
 approach the spherical form, while the others are polyhedric 
 through reciprocal pressure. 
 
 " The protoplasma of these singular cells is in general granu- 
 lous, with large grains. It takes a brownish yellow color under 
 the action of picrocarminate, except in the portions constricted or 
 in the form of pedicles, which portions 
 are more homogeneous and more re- 
 fractive. These generally possess large 
 nuclei, with one or several voluminous 
 nucleoles. Those that present several 
 distended portions have nuclei in each 
 of these portions. It will be perceived 
 that they are elements that proliferate 
 and bud with very great activit}^'' 
 
 The epithelium of a cyst-cavity, after 
 having undergone the changes of type 
 already described, takes on a further 
 growth, and, departing from an arrange- 
 ment in a single layer, as seen in the 
 normal follicle (Fig. 13), or in the cyst 
 still containing an ovum, it increases in 
 thickness, adding layer upon layer of 
 the immature cells. As these layers 
 grow, the cells alter more and more 
 from the normal and adult forms, and 
 finally cease to have any resemblance to 
 them. Waldeyer, as well as De Sinety 
 and Melassez, have fully confirmed my observations on this point. 
 The new layers are not uniformly distributed over the interior 
 of the same cyst, and they are often so localized as to form 
 elevated patches, or even tubercles, on the inside of the cyst. 
 To the naked eye these often look very like cancer, and on mi- 
 croscopic examination they have all the appearances which I 
 have already described as belonging to that tendency. The 
 French authorities I have so often quoted say of these masses : 
 ''They have the aspect of carcinomatous fungosities, and they 
 appear also to have their malignity." Boettcher and Waldeyer, 
 besides other authorities, fully support my conclusions. 
 
 In soine tumors we find velvety-looking tufts hanging from 
 the walls into the interior: and these are found, on examination, 
 to consist of a basis of nucleated fibrous tissue — in fact, ovarian 
 stroma — lined on each side of their many branches by regular 
 
 10 
 
 Altpred Kpithehum from 
 Walls of Ovarian Cysts. (After Da- 
 Sinety and Melassez.)
 
 146 DISEASES OF THE OVARIES. 
 
 columnar epithelium, or by epithelium of the immature forms. 
 They are sometimes, in fact, transformed into pediculated masses 
 of villous cancer. 
 
 As these structures divide and redivide into branches, they 
 very much resemble trees, and therefore have had conferred 
 upon them, among other names, that of intracystic dendritic 
 growth. If a cyst in which they exist be injected and. the sec- 
 tions stained, they will be found to consist merely of the remains 
 of follicles which have burst in their efforts to become cystic, 
 the skeleton branches retaining the epithelium of the cysts which 
 formerly were on each side of it. By the growth of subsequent 
 cysts these papillary remains are often forced into irregular and 
 very complex folds, the apparent complexity of which may be 
 greatl}^ increased by the accidents of the section. 
 
 We have here, therefore, among other things, an explanation 
 of the extraordinary differences of opinion which have been ex- 
 pressed regarding the results of microscopic examination of the 
 contents of ovarian tumors. Many years ago Professor John 
 Hughes Bennet described what he termed an "ovarian cell." 
 Dr. Drysdale, Mr. Thornton, and several others, have all fallen 
 into a similar error in believing that any one form of cell could 
 be made diagnostic of these curious growths. 
 
 In the second edition (18G8) of his book on " Ovarian Dropsy" 
 Mr. Baker Brown discusses the views of Professor Bennet, of 
 Edinburgh, who believed that it was possible, by microscopic in- 
 vestigation, to decide as to whether the fluid w^as ovarian or 
 peritoneal. Mr. Brown, in conjunction with Mr. Nunn, seems to 
 have gone very fully into this matter, and, in the words of the 
 latter, it seems to have been decided as follows: 
 
 '• I am inclined to say, as the result of many examinations 
 of different specimens of ovarian fluid, that the most constant 
 characteristic of such fluid is its containing, in greater or less 
 abundance, cells gorged with granules, and, in addition, circum- 
 ambient granules having the same measurements as those en- 
 compassed by the cell-wall. At one time I considered the size 
 of these granules was constant, but subsequent observations have 
 convinced me of the incorrectness of this conclusion. The size 
 of the gorged cells and of the granules varies greatly, even in the 
 fluids from different cysts of the same ovary." " In the present 
 state of our knowledge I do not think we are justified in assert- 
 ing that the nature of the fluid would be diagnostic of the dis- 
 ease which gives rise to its production. What I believe to be 
 the value of a microscopical examination of the fluid is that it 
 may serve to strengthen an opinion, but alone it ought not to 
 decide one."
 
 
 
 
 ^^•^eCo G . 
 
 i «V©<> 
 
 
 
 
 »<»; 
 
 O o 
 
 

 
 OVARIATT TUMORS, CONDITIONS WHICH SIMULATE THEM. 147 
 
 We may also find, from the observations of De Sinety and 
 Melassez, a confirmation of what I advanced many years ago in 
 a discussion upon tliis subject: that there was no kind of cell of 
 epithelial origin that it was not possible to obtain from the cyst- 
 cavities of an ovarian tumor. ' 
 
 In the last paragraph quoted from the French authors there 
 is a most concise description of what must also be regarded as a 
 tendency to malignant growth; that is, the reversion of type in 
 the production of these cells toward immature, incomplete, and 
 rapidly growing elements which are practically cancerous. 
 
 This of course at once explains the clinical fact which all ova- 
 riotomists are quite familiar with, and to which Dr. Keith has 
 especially drawn attention — that the rupture of certain cysts, on 
 the escape of their fluid into the peritoneal cavity, is followed by, 
 or at least is associated with, the infection of the general perito- 
 neal surface with papillary cancer, this accident having a uni- 
 formly fatal result. On the other hand, I have seen over and 
 over again the same cells and the same expressions of immature 
 growth in the peritoneum, without the presence of any ovarian 
 tumor; and only on the morning in which this sentence was 
 written I opened the abdomen of a patient placed under my care 
 by Mr. Oliver Pemberton, in which I found exactly the condition 
 so accurately described by De Sinety and Melassez in the above- 
 quoted sentence, but with no ovarian tumor. Now that we open 
 the abdominal cavity with great frequency, we are constantly 
 coming across this peculiar form of malignant disease, and we 
 find it is by no means confined to the inside of ovarian tumors 
 or to the peritoneal cavity, even when no tumor exists there, for 
 I have had occasion to examine pieces of the pleura and of the 
 pericardium where exactly the same appearances were found. ^ 
 
 The conclusion from all this is that to which I have already 
 pointed, that the growth of ovarian tumors is associated with a 
 tendency toward malignant disease, which finds constant clini- 
 cal expression, and whick receives its explanation in the mar- 
 
 ' Dr. Mathews Duncan speaks of this question with his usual force in these words : 
 " In fact, we have, in all departments of ovarian diagnosis, more to admire in the zeal 
 and diligence of histologists, in regard to the fluids, than in the exactness and relia- 
 bility of the practical results they can show." 
 
 ■^ But my most recent experience tends to show that there are two forms of pap- 
 illoma associated with ovarian tumors, one malignant, and one not so. The latter 
 speedily disappears after the removal of the tumor and the patient gets quite well, 
 though its naked-eye appearances are quite indistinguishable from those of the malig- 
 nant kind. I have had two cases within the last year, aged 57 and 38 respectively, 
 where I have left large masses of papilloma, fixing the uterus in both cases. Since 
 the operations these masses have entirely disappeared, and the patients are both in 
 perfect healtli.
 
 148 DISEASES OF THE OVAEIES. 
 
 vellous changes we find produced in the epithelial linings of its 
 cysts. Much more requires to be done in the study of this most 
 interesting question, and doubtless, when the method of its prog- 
 ress is made clear, we may find some indications for a more sure 
 prevention of it. One thing I am certain it clearly establishes, 
 and that is the absolute propriety of removing ovarian tumors 
 at a very much earlier stage of their existence than has been, 
 till recently, the accepted rule in practice. If these epithelial 
 changes are progressive — as doubtless they are, and if they are 
 malignant — as I certainly believe them generally to be, then, 
 acting upon the principles which guide us in the treatment of all 
 tumors, we ought to remove an ovarian cystoma early in its his- 
 tory, before these changes have been effected, and certainly be- 
 fore there is any risk of cyst-rupture. Finally, we ought to regard 
 the operation of tapping as one which ought to be discarded, 
 save under very exceptional circumstances, because not only is 
 it fraught with considerable immediate danger, but it seems to 
 possess a still more important secondary risk, which has until 
 lately been almost overlooked. I may say that in my own prac- 
 tice it is an operation never performed, unless I am certain the 
 tumors cannot be removed. 
 
 There is one fact which maybe quoted in support of the views 
 advanced by De Sinety and Melassez, to which they have not 
 drawn attention, but the significance of which becomes apparent; 
 that is. that while, in the cysts of the tumors which I shall after- 
 ward describe as possessing ova, the contents are always limpid, 
 whereas in the cysts where the changes have occurred the con- 
 tents are mucous, viscous, highly albuminous, and often bloody; 
 in fact, they present all the characteristics which the contents 
 of mucous cysts would possess. It might not be inappropriate 
 also to point out here that the arguments I have given above 
 also point in the direction of establishing for cancer a local ori- 
 gin. We have. then, ovarian tumors with well-pronounced and 
 distinctive characters, possessing the jjiower of infecting the sys- 
 tem generally with cancer, as the}^ most undoubtedly do when 
 their removal is too long delayed, or when they have ruptured 
 or been frequently tapped; and, on the other hand, we have tu- 
 mors with the same characters, but which have never been 
 tapped and have not ruptured, but have been removed early in 
 their histor}^ By the early removal of these latter tumors we 
 remove the source of the systemic infection, and prove, it seems 
 to me, a local origin for cancer — as far as the ovary is concerned, 
 at least. 
 
 There comes then the question — if we should see any of these 
 altered and sprouting cells in fluid removed from a cyst or from
 
 OVARIAN TUMORS, CONDITIONS WHICH SIMULATE THEM. 149 
 
 a serous cavity — Should we set the case down as bemg hopelessly 
 malignant, and, in the case of an ovarian cyst, refuse on that 
 account to operate? I certainly could not answer these questions 
 in the affirmative. I believe that such appearances indicate the 
 high road to cancer, but it is possible that the goal may never be 
 reached. I think it perfectly certain that removal of the tumor 
 may arrest the progress of the change before a general infection 
 is reached. Dr. Mathews Duncan very well points out that the 
 ovary is in every way the most isolated organ in the body. Re- 
 moval of a cystoma in which such changes are being effected, at 
 an early stage, may avert a systemic affection; and, as a matter 
 of fact, I have observed all these changes in tumors which I re- 
 moved many years ago, and the patients from whom they were 
 cut out are alive and well at this date. In one case the period 
 which has elapsed is eleven years. 
 
 Upon the question of the origin and diagnosis of this condi- 
 tion a good deal has been written, especially by Dr. Foulis, of 
 Edinburgh, and Mr. Thornton, of London. They both claim the 
 credit of having discovered masses of sprouting epithelium, both 
 in the cystic fluid and in that of the peritoneum, which will 
 enable us to diagnose cases of cancer. After a very large experi- 
 ence, both of microscopic manipulation and of cases of this char- 
 acter, I must absolutely dissent from the views they express. 
 Dr. Foulis goes so far as to say that the absence of these sprout- 
 ing masses from ascitic fluid is an almost certain sign of the 
 absence of malignant peritonitis and malignant ovarian tumor. 
 But I have had, in at least two cases, reason to suspect malignant 
 tumors, when I found none of these cells in the fluid, and yet I 
 found abundant reason afterward to know that my suspicions 
 were correct. In fact, I place no reliance on the presence or ab- 
 sence of these cells in fluid removed by tapping, and as I never 
 tap removable tumors at all now, I never have any occasion to 
 look for them, or any opportunity. The changes to which their 
 presence is due certainly lead to a malignant condition in their 
 later stages, but their presence is no guide for a prediction that 
 the patient will die of cancer, and it is the best of all arguments 
 for the speedy removal of the tumor. 
 
 It is also quite certain that this form of papillary cancer fre- 
 quently arises long after the removal of an ovarian tumor under 
 circumstances which make it extremely unlikely that the tumor 
 should be regarded as its cause. They are both probably the 
 result of the same condition, whatever that may be. Thus, in 
 the Lancet of October 25, 1875, I published a brief note of a casa 
 of ovariotomy in a young girl, in which the operation was mad(i 
 to cure a complete protrusion of the uterus. The operation wa'. 
 I
 
 150 DISEASES OF THE OVARIES. 
 
 performed on August 18, 1875, and after her recovery from it, until 
 about May, 1877, she remained in perfect health. She came to me 
 then with indications of a general failure in her health, obscure 
 pelvic pains, a slight amount of ascites, and a small fixed mass 
 behind the uterus. For a month she took chalybeates, and re- 
 turned to me much improved in her general health, but with 
 more ascites and with the retro-uterine mass increased. In the 
 beginning of July the increase of the ascitic effusion was so 
 marked that it became evident something must be done. The age 
 of the patient (nineteen) made me hesitate to pronounce it a case 
 of cancer of the peritoneum, to which view I strongly inclined. 
 The only alternative which seemed to me reasonable was that 
 the other ovary had become cystic, was fastened in the pelvis, 
 and was producing the ascites by pressure on veins, I deemed 
 it therefore right to make an exploratory incision, and this I did 
 on July loth. In the operation the only noteworthy point was 
 the absolute perfection with which union had taken place between 
 the tendinous structures divided in the previous operation — a 
 result which is not always obtained after abdominal section. 
 
 When the peritoneum was opened and the fluid evacuated, the 
 lesion was found to be the papillary form of cancer of the perito- 
 neum. Small papillary nodules were scattered over the whole 
 surface of the parietal peritoneum within reach, and on the sur- 
 face of the small intestines. The pelvis was occupied by several 
 masses, the largest of which, about the size of an orange, seemed 
 to embrace the rectum, and this it was which had been previously 
 felt from the vagina. At the posterior surface of the uterus 
 several nodules were felt, but the remaining ovary (the left one) 
 was perfectly healthy. The right cornu of the uterus was tied 
 up to the lower angle of the wound by a firm band about a third 
 of an inch in diameter, representing the pedicle of the tumor re- 
 moved nearly two years before. She recovered from this opera- 
 tion, went home, and died after great suffering, on the 27th of 
 August. I have again examined the tumor removed from her 
 with great care, and can discover no appearance of papillary 
 growths about it, and, as she remained in perfect health for at 
 least eighteen months after the operation, I can only regard the 
 access of the papillary growth as an independent event. 
 
 There is another condition associated with malignancy in ova- 
 rian tumors — hemorrhage into their cavity. I have seen one 
 case where this occurred, yet where the tumor was not cancer- 
 ous; yet, as a rule, its occurrence must always be regarded as 
 suspicious. 
 
 The following is a typical example of a case of <;ystic tumor 
 of the ovary which has undergone malignant degeneration — one
 
 OVARIAN TUMORS, CONDITIONS WHICH SIMULATE THEM. 151 
 
 in which the mistakes I fell into have been of immense service 
 to me since. 
 
 On March 2, 1876, I was summoned to the neighborhood of 
 Llangollen to see a patient under the care of Dr. Price Jones, from 
 whom I received the following history: She had been confined 
 of her first child on February 21st. The labor was natural, the 
 child still-born, the placenta somewhat friable, but expelled with- 
 out difficulty. She did not, however, diminish in size as much 
 as usual after labor, and in a day or two symptoms of peritonitis 
 appeared. On February 28th her pulse and temperature fell to 
 100 and 99° respectively, and the only matter of note was that 
 the abdomen was greatly distended by fluid. At 2 a.m., on March 
 2d, I found the abdomen so distended as to have quite a drum- 
 like tightness, the temperature quite normal, but the pulse about 
 180 and the respirations 50 in the minute. These symptoms were 
 regarded as due solely to the mechanical interference with 
 breathing. The uterus was fixed high up in a solid, doughy mass, 
 which could only be blod-clot. No intestinal resonance could any- 
 where be discovered. Generally over the abdominal surface a 
 wave of fluctuation could be felt, but here and there it was less 
 distinct. Palpation gave no assistance on account of the tenseness 
 of the integument. The conclusion I came to was that it must 
 be a case of intraperitoneal hsematocele followed by some serous 
 effusion; for I regarded it as impossible that it could be all blood. 
 I tapped the abdomen, and removed about three quarts of fluid, 
 which seemed like pure venous blood. This gave immediate 
 relief; and when I left her, at 7 a.m. on March 3d, the pulse had 
 fallen to 120 and the respirations to 32 in the minute. The relief 
 of the tension also enabled me to discover floating doughy 
 masses, which I regarded as blood-clot. She improved consider- 
 ably after this, and was brought to Birmingham on March 30tli. 
 The journey was delayed as long as possible; but she became so 
 urgent for something more to be done that it was impossible to 
 appease her any longer. The exertion of removal was, however, 
 evidently too much for her, as on the following day a passive 
 oedema of the left thigh occurred, and this was followed by an 
 increase in the size of the abdomen. This latter condition be- 
 came so serious on April 2d that it was necessary to tap her 
 again, and eight pints and a half of a fluid which seemed like 
 equal parts of blood and water were removed. The breathing 
 was greatly relieved by this for a few hours; but on the after- 
 noon of the next day it became again very bad, and, as it then 
 seemed to come from the chest, Dr. Heslop was called to see her 
 in my absence. It was then discovered that the left pleura was 
 full of fluid, and three pints and a half were immediately re-
 
 152 DISEASES OF THE OVARIES. 
 
 moved from it by aspiration. This quite relieved her breathing. 
 As the fluid was distinctly tinged with blood, Dr. Heslop sug- 
 gested that there might be some malignant disease in the chest; 
 but, on careful discussion of the whole aspects of the case, there 
 was no sufficient data to arrive decisively at such an unfavorable 
 conclusion, as it was thought possible that the pleural effusion 
 might have been the result of mechanical pressure from the ab- 
 domen. On April 4th, 5th, and Gth she was very comfortable ; 
 and, after careful discussion, it was determined to open the 
 abdomen to determine if anything could be done to arrest the 
 hemorrhage. In cutting open the abdomen, a line of abnormal 
 tissue was cut through which looked like malignant growth, and 
 then a cavity was opened which contained a quantity of bloody 
 fluid and thick layers of laminated fibrin. As no point of 
 hemorrhage could be detected, and as it was felt that any dis- 
 turbance of the structure might lead to hemorrhage which might 
 not be controllable, the cavit}'- was washed out with thymol 
 solution, a drainage-tube inserted, and the wound closed. The 
 nature of the case was not made absolutely clear by the section, 
 as no accurate idea could be formed as to the nature of the pos- 
 terior wali of the hsematocele cavity. She died on the afternoon 
 of April 9th. The i^ost-mortem examination was made by Dr. 
 Saundby, who found that the left pleural cavity contained about 
 two quarts of blood-stained serum, the lung being quite collapsed, 
 but healthy. There was a f ungating ulcerated growth about 
 the size of a walnut, covered with blood-clot, on the pleural sur- 
 face of the diaphragm. The right pleural cavity contained about 
 a pint and a half of similar fluid, with a similar growth on the 
 diaphragm. Some of the mediastinal glands were as large as 
 hens' eggs from cancerous infiltration. The abdomen was occu- 
 pied by a large tumor matted down to the uterus, broad liga- 
 ments, and section, and only after careful dissection could it be 
 made out that this mass was a cancerous tumor of the left ovary, 
 that into its cavity the hemorrhage had occurred and the in- 
 cision had been made. It was adherent over the whole of its 
 anterior aspect to the abdominal wall. The microscopical ap- 
 pearances were those of encephaloid cancer. 
 
 Looking back on this case, I of course regret that I performed 
 abdominal section; indeed, I did so against my own convictions 
 and entirely at the patient's most urgent request. I had the 
 advantage of the help of Dr. Marion Sims in the case, and there- 
 fore had as good security for avoidance of error as could be — yet 
 we were all mistaken. 
 
 The term colloid, as applied to tumors of the ovary, must be 
 held to refer only to the consistency of the fluid contained in them,
 
 OVAKIAN TUMOKS, COXJDITIOX.S WHICH SIMULATE THEM. 153 
 
 and in no way as a jjoint for classification. I have never met 
 with a description which has persuaded me that the so-called 
 colloid cancer, as seen in the breast, intestines, and peritoneum, 
 has ever been met with in the ovary. What we see of it is the 
 myxoma already described, and which is always quite localized 
 in the tumor, a mere incident, as it were, never forming the mass 
 of the growth. In other organs it is practically a malignant dis- 
 ease, but whether it is so in the ovary I do not know. It is, as I 
 have said, the reversion of the stroma of the ovary to its young 
 form, and may therefore be suspected. The first time I saw it was 
 in a tumor sent to me for examination by Mr. Spencer Wells, wlio 
 asked the question, '" Do you 
 think this cancer ? '' In my 
 reply I said I feared it was ; 
 the stroma was so young and 
 immature as to resemble per- 
 fectly a myxomatous growth, 
 or the canalicular structure of 
 the umbilical cord. Indeed, if I 
 had placed sections from these 
 three structures under adjoin- 
 ing microscopes, I do not think 
 that I have yet met with the 
 histologist who could distin- 
 guish between them. 
 
 An example of this disease 
 was exhibited before the Ob- 
 stetrical Society of London, in 
 June, 1878, and as it illustrates 
 not only this disease, but the 
 fact that diseased ovaries lead to intractable menorrhagia which 
 kills the patient, I shall quote the report in full. If instead of 
 using a sponge tent, which merely had the effect of killing the 
 enfeebled patient by septic peritonitis, the surgeons had removed 
 the patient's ovaries, they would have removed the cause of the 
 hemorrhage, and probably have saved and cured their patient. 
 The victim, a woman aged twenty-one, had suffered from al- 
 most constant hemorrhage since her marriage three years pre- 
 viously ; and when admitted into Guy's Hospital she was so 
 exhausted that transfusion was thought of. The hemorrhage, 
 however, was checked by the use of a sponge tent and the sub- 
 sequent injection of warm water, but the woman died ten days 
 later of suppurative peritonitis. Both ovaries were found en- 
 larged, but retaining their normal shape ; and it was at first 
 thought that the enlargement was due to acute inflammation. 
 
 Fig. 2T. — Mj'xomatous (growth of Ovary.
 
 154 DISEASES OF THE OVARIES. 
 
 Microscopical examination, however, showed that the histologi- 
 cal characters of the growth were those of myxoma, though 
 the harder portions exhibited the characters of sarcoma. The 
 spleen was leuksemic. The uterine mucous membrane was dis- 
 integrated on its surface (as shown in one of the microscopical 
 sections) and altered in structure, its round cells appearing 
 separated, as if by fluid effused between them, and being sur- 
 rounded by a fibrillar growth, reminding one of the state of 
 things found in the ovaries. He would leave it, the reporter said, 
 to the pathologists to decide whether there was any connection 
 between the leukaemia, from which the patient suffered, and the 
 myxomatous enlargement of the ovaries. 
 
 The structure of the walls of ovarian cystomata is tolerably 
 uniform, but it is so often altered by protracted growth and in- 
 flammation of the tumor that it may be difficult, in many prep- 
 arations, to identify the structures. If a tumor be examined 
 which has not been so altered, it will be found that the structures 
 met with are pretty much as follows: 
 
 In the first place, if the outer surface of the tumor be exam- 
 ined while it is perfectly fresh, before it has been damaged by 
 rough handling, and if the preparation be made in the way I 
 shall describe, it will be found that this membrane has all the 
 characters of a normal serous surface. A mosaic of flat, poly- 
 hedrous cells, with the characteristic cement substance between 
 them, will be found extending uniformly over the surface of the 
 tumor. The method of examination which I pursue is that of 
 spreading a small portion of the tumor over a slightly convex 
 surface, such as a watch-glass, and placing it in my freezing 
 microtome with distilled water only. I then screw it carefully 
 up to the level of the cutting-slab, and take a thin slice off the 
 outside surface of the tumor. This is immersed in a solution of 
 .5 per cent, of lactate of silver, and is then mounted in glycerine 
 jelly. This treatment brings out all the structures I have de- 
 scribed in similar situations, and we see the stigmata and sto- 
 mata, with the characteristic endothelium of the latter, just as 
 we find them in all other serous pavement surfaces. From the 
 endothelium of the stomata I have an absolute assurance that 
 the malignant growths of which I have spoken, and of which I 
 shall have to speak again, are derived. They constitute a va- 
 riety of epithelioma, and are, in my estimation, analogous to the 
 nesting of the epithelial cells which we see in skin cancer. These 
 cells are produced by a rapid and immature proliferation of the 
 endothelium of the stomata. In a favorable section they may 
 be seen to be crowding out of a stoma, tearing asunder the rela- 
 tions of the epithelium to its subjacent structure; and thus it is
 
 OVAKIAN TUMORS, COISTDITIONS WHICH SIMULATE THEM. 155 
 
 that they possess to the naked eye and to the touch the peculiar 
 characteristics which have obtained for this disease its special 
 names of papilloma and miliary cancer. It will be seen, there- 
 fore, from this description, that it differs in no way from any 
 other form of epithelioma, and it is to be seen on the surface of 
 an ovarian tumor as often as it is to be seen either on its inside 
 or upon the peritoneum without the presence of an ovarian tu- 
 mor at all. 
 
 The descriptions given by De Sinety and Melassez of the ex- 
 ternal surface of an ovarian cystoma differ very materially in 
 some points from my own, but I have only to point to their 
 methods of examination as affording a complete solution of the 
 discrepancy. I have already said — in a paper read before the 
 Royal Society upon the "Anatomy of the Umbilical Cord " — that 
 no correct descriptions can be given of any tissue from a micro- 
 scopical examination made upon anything but perfectly fresh 
 tissue, and this is most peculiarly true of an epithelial surface. 
 To employ any hardening reagent, and then describe what is 
 seen, is, therefore, not describing what may be seen in fresh tis- 
 sue. "When the French authorities say: "That by employing 
 these two processes we have assured ourselves that the exterior 
 investment of the walls in no way resembles the endothelium 
 investment of the peritoneum," the difference between their de- 
 scription and mine is further to be explained by the different use 
 of the term endothelium. They seem to employ it to mean a sub- ' 
 epithelial layer of cells, while I use it, on the authority of Dr. 
 Klein, exclusively to mean the cells within the stomata ; and 
 while there can be no doubt that the subepithelial arrangements 
 are altogether different in the ovarian cystoma from those of 
 the peritoneum, because the structures are in themselves alto- 
 gether different, the subepithelial arrangements of an ovarian 
 tumor are precisely those of the ovary. 
 
 Underneath the epithelial layer which I have just described 
 there is a layer of fibrous stroma of varying thickness, and hav- 
 ing a variety of structures in it. The stroma is stated by differ- 
 ent authors to be capable of subdivision into a varying number 
 of layers — from two to six — the only point of agreement between 
 them being that the divisions are most marked at the point of 
 implantation of the tumor. Thus, De Sinety and Melassez say: 
 
 " In the neighborhood of the point of implantation may thus 
 be obtained three principal layers: one external, in connection 
 with the peritoneal cavity; one internal, in connection with the 
 cystic cavity; and one medium, interposed to the two preceding. 
 The external and internal layers have the aspect of fibrous mem- 
 branes, while the medium layer has rather the aspect of loose
 
 156 DISEASES OF THE OVARIES. 
 
 cellular tissue. It is in this latter layer that the large vessels of 
 the pedicle spread themselves out. Departing from the base of 
 the tumor, the medium layer becomes thinner, is no longer isola- 
 ble, and the cystic wall then appears to be formed only of two 
 fibrous layers. Still farther toward the summit of the tumor the 
 cystic walls are thinner, and can no longer be dissociated into 
 several layers, except by the aid of a most artificial dissection. 
 They are no longer anything but a fibrous membrane, homoge- 
 neous in its whole thickness. These transformations are easily 
 explained. The}^ are due to the medium layer of loose cellular 
 tissue becoming thinner and thinner, and finally disappearing, 
 and to the internal and external fibrous layers adhering together 
 and becoming intimately blended." 
 
 Concerning these various statements I would only say that a 
 skilful dissector could manage still further to subdivide them, 
 and the results obtained in this dissection would, of course, be 
 very materially influenced by the number of diseased follicles in 
 the neighborhood where he was working. 
 
 The microscopic structure of this middle layer varies very 
 much with the age of the tumor. In an old example with thick- 
 ened and hardened walls, more particularly if it has been fre- 
 quently tapped, the elements are almost entirely fibrous, with 
 here and there a few indications of nuclear arrangements of the 
 proper ovarian stroma, the almond-shaped nuclei being often so 
 altered and elongated that they are taken for the rod-shaped nu- 
 clei of unstriped muscular fibre. I have, however, never been 
 able to satisfy myself in a single instance of the presence of mus- 
 cular fibres in the walls of an ovarian cystoma ; while, on the 
 other hand, in the parovarian cyst it is an almost uniform expe- 
 rience to find muscular fibre largely entering into its constitu- 
 tion. Dr. Grailey Hewit has described an ovarian tumor with 
 muscular envelope, but on reading the account I had no doubt 
 whatever that what he found was a parovarian and not an ova- 
 rian cystoma. I have myself seen a mass of muscular fibre in 
 an example of the former almost half an inch thick. 
 
 De Sinet}^ and Melassez, however, speak of having found a 
 great abundance of unstriped muscular fibre in the walls of an 
 ovarian cystoma, an observation the results of which are open 
 to various explanations. They speak as a conclusion to be drawn 
 from their researches, that the employment of ergot of rye may 
 have the result of arresting the growth of ovarian cystoma by 
 reason of its power over involuntary muscular fibi*e, and they 
 actually quote a case in which hypodermic injections of ergotin 
 are supposed to have cured one. I cannot, however, assent to 
 anything which would involve the application of therapeutic re-
 
 OVARIAN" TUMORS, CONDITIONS WHICH SIMULATE THEM. 157 
 
 suits for the establishment of microscopical or pathological in- 
 vestigations. In the words of Dr. Mathews Duncan I may say 
 that '•' we know of not one single case of cure of an ovarian cys- 
 toma by any other proceeding than that of the operation of 
 Ephraim McDowell.'' 
 
 In the wall of a cyst of recent growth we constantly find the 
 remains of normal Graafian follicle, to which there had not ex- 
 tended the mysterious influence which directs cystic develop- 
 ment ; but in an old tumor these are not readily found, for they 
 have either already developed into cysts, or the advancing scle- 
 rosis has altogether destroyed their characters. At its base an 
 ovarian tumor may easily be separated from its peritoneal cap- 
 sule, just as a normal ovary may be, and upon this fact is based 
 the ingenious treatment of sessile tumors by enucleation, origi- 
 nally suggested by Dr. Miner. 
 
 Among the conclusions made by De Sinety and Melassez is 
 one to the effect that a large number of ovarian cystomata have 
 their origin in the tubes of Pfliiger. Now, these tubules have 
 been the cause of a great deal of discussion, and I, for one, am 
 perfectly satisfied that they have received an amount of atten- 
 tion, and have been elevated into an importance they do not de- 
 serve. In Figures 7 and 9 very fair representations of these 
 tubes are given, after Balfour. They are confined entirely to the 
 hilum of the organ, being, as I have said, survivals of the Mal- 
 pighian tubes, and therefore no part of the true structure of the 
 ovary. I have never yet seen them lined with epithelium, and 
 therefore I do not believe they are capable of undergoing cystic 
 development, for without epithelium I do not think any such pro- 
 cess could occur. In all probability they have some kind of epi- 
 thelium in the early stages of their existence, but if they ever 
 had any at all they lose it in more mature growth. It is possible 
 that in occasional instances they may retain it, and then be de- 
 veloped, just as the tubules of the parovarium; but I have never 
 seen any case in which I had reason to believe these tubes were 
 the origin of the cysts. If they should give rise to a cystic tu- 
 mor, one would suspect it ought to be of a unilocular character, 
 and that its walls would not possess the features which are 
 always characteristic of an adenoid cystoma. 
 
 In the Archives fiir Gijnekologie, 1870, Waldeyer confirms 
 this view in a remarkable sentence: ''My researches have de- 
 monstrated to me that the opinion of Foster and Rindfleisch, to 
 the effect that cystomata originate from the connective elements 
 of ovarian stroma, is not admissible;" and with this opinion I 
 entirely agree. It will be seen, therefore, that, with the excep- 
 tion of the possible occurrence of an occasional unilocular cyst
 
 158 DISEASES OF THE OVARIES. 
 
 arising from the tubules of Pfliiger, my belief is that all ovarian 
 cystomata have their origin in follicular dropsy. 
 
 I have failed to find any description of a cartilaginous growth 
 of the ovary apart from cystic alteration, but I have twice found 
 plates of cartilage in the walls of ovarian cysts, and in neither 
 of these tumors were there any other structures which might 
 place them in the category of dermoid cysts. The cartilage was 
 composed of large cells with very little fibrous matrix ; in fact, 
 it was hyaline cartilage, identical with what I have seen repeat- 
 edly in the testicle. There is, of course, no good reason why en- 
 chondromatous tumors should not be met with in the ovary, just 
 as they are in the testicle ; but in the latter organ they occur 
 independently of cystic degeneration, while I am not aware that 
 they ever have done so in the ovary. 
 
 Fibromatous tumors of the ovary must be very rare, for I 
 have only met with three cases, and one which was clearly malig- 
 nant. Growth of the fibrous stroma of the ovary, so as to form 
 a large abdominal tumor requiring removal, has not yet been 
 described, so far as I have been able to discover; and under any 
 circumstances the condition is a rare one, for Peaslee has col- 
 lected only seven cases, including two which he had seen him- 
 self, and Atlee describes another which probably was of this na- 
 ture, though unfortunately no microscopic examination of it has 
 been recorded. I think that if I had a similar opportunity now 
 of examining such a preparation, I should be able to give a much 
 better account of it, for I suspect that the reason of its malig- 
 nancy would be capable of explanation by reversion to an imma- 
 ture form of growth of the cells of the ovarian stroma, analogous 
 to that of the cystic epithelium. 
 
 The patient in whom occurred the first of the tumors I am 
 about to describe was forty-four years of age, was very stout, had 
 borne six children, and had been failing in health, owing to the 
 increasing size of her abdomen, for about two years. She was 
 sent to me by Dr. Vinrace in July, 1873, when I found the abdo- 
 men occupied by a large quantity of ascitic fluid, in which floated 
 a large and perfectly solid tumor. The abdominal walls were 
 also very oedematous. I tapped the abdomen and punctured the 
 skin repeatedly with a lancet to get quit of the anasarca. This 
 was repeated several times, until it was evident that only the 
 removal of the tumor, which I had diagnosed to be solid ovarian, 
 would permanently benefit the patient. When the abdomen was 
 opened, it was found necessary to extend the incision eight centi- 
 metres above the umbilicus, in all nearly twenty-five centimetres, 
 before the tumor could be removed. It had an adhesion to a coil 
 of intestine, and a very extensive adhesion to the^ great omen-
 
 OVARIAN TUMORS, CONDITIONS WHICH SIMULATE THEM. 159 
 
 turn, and it occupied exactly the relations of the left ovary, the 
 other being perfectly healthy. Its pedicle was clamped, and the 
 wound closed in the usual way. The patient died on the fifth 
 day, as was usual when the clamp was employed. The tumor 
 was round, smooth, and of a creamy white color, and it weighed 
 almost nine pounds. When cut into, it had a glistening, white, 
 and trabeculated structure; and it was perfectly solid throughout, 
 there being no indication anywhere of cystic formation. A num- 
 ber of very thin sections were made, and these were treated by 
 various processes, their uniform result being to show that the tu- 
 mor really was the ovary, and that its overgrowth was limited to 
 the fibrous stroma. The fibres were ranged in bands which 
 crossed in all directions, and treatment by acetic acid showed 
 that a few of these bands, or perhaps I should say a very few, 
 were composed of muscular fibres, an observation which substan- 
 tiates that of Sanga.li, quoted by Virchow, made in a similar but 
 much smaller tumor. Looking at my sections of this tumor, 
 made nearly ten years ago by the rough processes in use before 
 I had introduced the method of cutting sections of fresh frozen 
 tissue, I cannot make out very much more now, but I feel nearly 
 satisfied that these fibres are but the result of immature fibre-cell 
 growth running to riot. Throughout the tumor, but chiefiy 
 toward its surface, a number of minute cavities were observed, 
 lined by epithelium, and having in one or two instances a large 
 cell with a nucleus, presenting all the appearances of an ovum. 
 The number of these cavities in a less pronounced condition was 
 very large, and I have no doubt they were immature Graafian 
 follicles. I have, within the last few days, removed an exactly 
 similar tumor of smaller size. The pedicle was ligatured, and 
 the patient recovered as usual without any difficulty. 
 
 A Microscopical Committee of the Philadelphia County Medi- 
 cal Society reported as follows on a tumor of a similar kind, sub- 
 mitted to them by Dr. Washington L. Atlee, and which he had 
 successfully removed in 1876: 
 
 '' Thin sections from both the fresh tumors and from hardened 
 preparations exhibited a dense, fibrous-looking stroma, in which 
 the spindle-cells apparently constituted but a small portion, the 
 large majority having, it seemed, been developed into the fully 
 formed fibrous tissue which gave its firm, dense character to the 
 growth. The application of diluted acetic acid brought into view 
 small oval nuclei, arranged with considerable regularity in the 
 section, and which, even under a high power (1,250 diameters), 
 displayed none of the double, triple, and multiple character com- 
 monly met with in neoplasmata of the more malignant type. 
 
 " Your committee, therefore, conclude that these two ovarian
 
 160 DISEASES OF THE OVARIES. 
 
 tumors are the spindle-celled sarcomata of Wagner, Virchow, 
 Rindfieisch, and other late German pathologists, and accurately 
 correspond with those described by Rokitansky as ' Fibrous Can- 
 cer,' and by Paget under the name of ' hard cancer with fibrous 
 structure.' 
 
 "According to Rokitansky, ovarian growths of this charac- 
 ter occur very rarely, and Scanzoni states that these ' fibrous 
 bodies ' of the ovary had, to his knowledge, only been proved to 
 exist in four cases, up to the time his work was revised, in 1858." 
 
 I have never met with that rare variety of fibroma of the 
 ovary, of which only three instances have been described — two 
 by Rokitansky and one by Klob — and in which small fibrous 
 growths arise from the corpus luteum. 
 
 In the "Transactions of the Obstetrical Society of London," 
 for 1874, Dr. Goodhart relates a case of fibroma of the ovary. 
 I)robably of this kind, in a woman aged forty-two, who died from 
 granular disease of the kidneys. She had several fibrous tumors 
 in the uterine wall, etc., as well as one in the ovary, which was 
 about one and one-half inch in diameter. The relations of the 
 tumor were accurately determined. It grew directly from the 
 free or epithelial surface of the organ, and had no connection 
 with the broad ligament. On section it was shown to spring 
 from the outer layer of the ovarian stroma — that part character- 
 ized as "tunica albuginea " by old writers, and as the condensed 
 external layer of the proper ovarian stroma by Waldeyer. 
 
 The case of malignant fibroma was one which I saw in Octo- 
 ber, 18G9, in consultation with Dr. Hollings, of Wakefield. She 
 had a large oval tumor, solid, hard, and smooth, moving freely 
 in the abdomen, centrally situated, with a similar smaller one to 
 the right side. The larger tumor reached about two inches above 
 the umbilicus, could be felt high in the pelvis, and had an attach- 
 ment to the uterus. I diagnosed it as a case of solid cancer of 
 the ovary, and declined to operate. The abdomen was free from 
 ascites or other complication. I saw her a second time in a few 
 weeks, and found that the tumors had both increased in size, 
 and then, having made myself more familiar with the subject, I 
 gave it as my opinion that it was an instance of the rarest of all 
 forms of cancer — the fibroid. On December 5th I found her with 
 symptoms of peritonitis, and a considerable effusion of ascitic 
 fluid. I tapped her, to relieve the breathing, and found a large, 
 soft, semi-fluctuating mass extending from near the xiphoid car- 
 tilage to within three inches of the pubis, masking the outlines 
 of the tumors. This I recognized as possibly a fungoid growth 
 of the omentum. I tapped her again on the 9th, and she* died 
 next day. Twenty-four hours after death I examined the body.
 
 OVAKIAIS" TUMORS, CONDITION'S WHICH SIMULATE THEM. 161 
 
 and, on opening the abdomen, I found adhesions everywhere to 
 the large, deep-colored fungous mass which I had correctly re- 
 garded as growing from the omentum. It was adherent behind 
 to the intestines and to the tumors. The larger of these latter 
 was found to be perfectly loose, save from the omental mass and 
 the right corner of the uterus, to which it was attached by a 
 short, thick pedicle; in fact, it was the right ovary, as no other 
 trace of the gland could be found. The smaller tumor was simi- 
 larly the left ovary, and a still smaller tumor seemed to grow 
 from the same pedicle. Scattered over the surface of the peri- 
 toneum were patches very similar to those previously described 
 as papillary cancer of the peritoneum. These patches were also 
 found on the surfaces of the tumors, and were stripped easily 
 off with their investing epithelial coverings. In the right or 
 largest tumor were a few cavities containing fluid, and also 
 some curious cretification at the base and in the pedicle. It 
 weighed probably twelve or thirteen pounds, so that I could not 
 remove it conveniently for preservation. I removed and care- 
 fully examined the smaller tumors, some peritoneum, with speci- 
 mens of the patches and a piece of the omental fungus. 
 
 In the piece of omentum nothing but blood-detritus, a few 
 scant fibres, and numbers of irregular cells were found, with im- 
 mense numbers of free nuclei, or what seemed to be such. The 
 nodules on the peritoneum showed all the characters of cancer- 
 ous tissue, being composed of large, irregularly shaped and 
 irregularly sized cells, containing variously shaped nuclei in 
 varying numbers. There seemed to be no fibrous tissue in them 
 at all, and their elements readily separated by gentle pressure 
 between the cover and the glass slide, A careful section showed 
 the epithelium of the free surface of the peritoneal layer to be 
 undergoing interesting changes. The cells of the upper layer 
 were normal, but at two or three layers' depth they were seen tO' 
 be larger, more irregular, and the number of nuclei increased, 
 the latter fact being most clearly displayed on the addition of 
 acetic acid. 
 
 The ovarian tumors removed were ovoid, smooth, and glis- 
 tening, and here and there the surfaces were marked with the 
 peculiar patches above described. Together, they weighed 
 nearly three pounds. When cut into, no juice exuded from 
 them, and the scant moisture scraped from the cut surface 
 showed no cells. The tissue was pearly white and very tough. 
 Teasing with needles did not give any satisfactory results, and 
 a great many sections had to be made before one thin enough 
 for examination was obtained, I then found that the texture 
 was purely fibrous, there being nowhere, under the epithelial 
 11
 
 163 DISEASES OF THE OVARIES. 
 
 layers, any cells discoverable. The fibres were extremely fine, 
 closely and regularly packed, without any appearance of undu- 
 lation or interweaving, but seemed to lie parallel, with only faint 
 curvings in their general direction. They were readily stained 
 by carmine. Acetic acid showed no nuclei, and did not influence 
 the fibres beyond a slight clearing of the section. The tumors 
 differed quite from those already described as fibroma, which do 
 not seem to be malignant. 
 
 It will be found that this description differs in some important 
 particulars from that given by Sir James Paget of similar struc- 
 tures, especially in the absence of nuclei ; but the rarity of op- 
 l^ortunities for the examination of such peculiar growths stands 
 much in the way of their proper investigation; and now we have 
 much better methods of examining such growths, so that future 
 experience will give far more precise results. ' 
 
 Among all the tumors I have examined I have never seen 
 any of the so-called osteomata; indeed it is greatly to be doubted 
 if any true osteoma has ever been found in the ovary, except as 
 part of a dermoid cyst. All the others, of which I have seen de- 
 scriptions, are evidently only instances of cretification. 
 
 This form of change has been very carefully studied by De 
 Sinety and Melassez, and they summarize their conclusions as 
 follows: 
 
 It is presented in two forms, of which the first and more sim- 
 jjle consists of a deposit of small calcareous grains in the con- 
 nective substance. Occasionally these appear deposited in the 
 interstices of two lamellae or two connective fasciculi, in the 
 place occupied by the connective cells; but that is only an ap- 
 pearance due to the calcification having commenced upon one 
 of the faces of the lamella or connective fasciculus. These little 
 grains of calcification are sometimes isolated, and sometimes 
 united in a band. This form rarely exists alone; it is habitually 
 met with associated with the second, of which it appears to be 
 the origin. 
 
 The second form consists of more or less extensive patches, 
 disposed parallel to the cystic surface. As we have already 
 said, there usually exists a layer of connective tissue between 
 them and the cystic cavity. Their internal or cystic surface is 
 generally smooth, and forms, upon sections, a rectilinear line; 
 while the external or deep face, and especially the extremities, 
 are irregular, and present excrescences or depressions. The ex- 
 crescences have almost always a rounded, semi-spherical form, 
 as if due to the addition of little calcareous grains to the princi- 
 
 Wilson Fox has noticed these de^'euerations of vegetations (loc. cit., p. 268).
 
 OVARIAN TUMORS, CONDITIONS WHICH SIMULATE THEM. 163 
 
 pal mass. The depressions are in the form of cupolse, rather like 
 those presented by bones attacked with atrophic osteitis; they 
 are sometimes situated in the interior of the calcareous patch, 
 and there form very irregular anf ractuosities. In the substance 
 of the patch may be discovered, further, the disposition of the 
 lamellae and connective fasciculi, fine striae indicating the place 
 occupied by the connective cells now destroyed. 
 
 Besides the formation of cystoma of the ovary from simple 
 distention of the Graafian follicle by an excess of its proper fluid, 
 Rokitansky and Arthur Farre long since drew attention to the 
 formation of ovarian cysts by hemorrhage into the cavity of the 
 follicle. In his classic article on tlie ovary in the '* Encyclopedia 
 of Anatomy and Physiology," Dr. Farre figures and describes 
 such a cyst as having ''its cavity filled with loose flocculi, of a 
 dark chocolate color, consisting of decomposed blood-clot mixed 
 with patches of membrana granulosa. The walls of the follicle 
 were not yellow, and contained no oil-globules, and they were 
 slightly thicker than those of the healthy follicle," Their com- 
 ponent tissues were precisely those he describes as characteriz- 
 ing the ovisac in its normal condition, and the main bulk of its 
 structure was made up of granules and embryonic fibres, inter- 
 mixed with a few developed fibres of ordinary white fibrous tis- 
 sue. He considers it to constitute one of the early stages of 
 these enormous growths, forming an ordinary cystoma of the 
 ovary. 
 
 Rokitansky regards these cysts as being due to a cystic de- 
 generation of the corpus luteum. He says they may exceed the 
 size of a walnut, that their interior surface is wrinkled, and their 
 exterior limit is easily recognized. 
 
 Cruveilhier speaks of ovarian hsematic cysts as a consequence 
 of an apoplexy of the ovary, and as a probable consequence of 
 an exaggeration of the small clot of blood produced in the ovary 
 at the rupture of an ovisac. These he says are often transformed 
 into perfectly organized serous cysts, of which the origin is 
 sometimes of very doubtful determination, though it may be re- 
 vealed by fibrous concretions within them or by the orange yel- 
 low coloration of their walls. The largest he had seen was in 
 the ovary of an old woman, in which the cyst was filled with a 
 dark brown matter having the consistence and color of water 
 chocolate. The walls of the cyst were greatly injected and were 
 patched with red, being infiltrated with blood in their thickness, 
 but otherwise they presented the usual appearances of the struc- 
 ture of the tunic of the ovisac. 
 
 De Sinetj'' and Melassez have made similar observations, and 
 I can substantiate all that these observers have noticed in
 
 164 DISEASES OF THE OVAEIES. 
 
 connection with the production of small-sized cysts from what 
 may be described as an apoplexy of the ovisac. I have no 
 doubt at all that they are the result of excessive hemorrhage 
 into the cavity, occurring either at the time of its rupture for 
 the discharge of the ovum, or perhaps occurring when the 
 ovum was not discharged as it ought to have been. In one case 
 I removed a tumor of this kind on account of persistent and 
 intractable uterine hemorrhage. Before the operation, which 
 was performed in 1873, I regarded the patient as suffering from 
 hemorrhage due to a uterine myoma, but when I opened the ab- 
 domen I found it was a true ovarian tumor, consisting of one 
 large cyst, and at its base a few small cavities. The large cyst 
 contained a dark purple material of the consistence of putty, 
 which was evidently the remains of blood-clot, the serum of 
 Avhich had been absorbed; and this material dried into a brittle 
 substance, exactly as blood-clot does. The removal of the tumor 
 arrested the uterine hemorrhage completely, and the patient 
 made an excellent and permanent recovery. Unfortunately at 
 that time I Avas not so conversant with the facts of ovarian 
 pathology as I now am. and the tumor was not properly exam- 
 ined, and the only note which I possess of its appearance, be- 
 yond what I have already described, is that on its inner surface 
 there was a large patch having an appearance as if it were ul- 
 cerated, and that this spot probably was the source of the hem- 
 orrhage. Upon this ulcerated surface tiiere was no appearance 
 of an epithelial layer. Before any conclusion of value can be 
 given from these cases some similar experiences would have to 
 be more carefully investigated, but I am strongly of the belief 
 that this tumor was an example of Rokitansky's haematic cyst, 
 which had reached a size and an importance which those struc- 
 tures do not usually possess. 
 
 I think that Arthur Farre's view is probablj^ correct, and that 
 when follicular dropsy begins as an apoplexy this character is 
 maintained for only a short time in its history, and that its after- 
 course is that of an ordinary cystoma. It is quite likely, how- 
 ever, that an occasional instance will be met with where the dis- 
 tention is due to recurrent hemorrhage, and of this I think my 
 case was probably an example. I cannot pretend, however, to 
 explain why this should be accompanied by the terrible uterine 
 hemorrhage from which my patient suffered; still less can I see 
 why the removal of the tumor should completel}^ arrest this 
 symptom. 
 
 The tubules of which the parovarium is made up, frequently 
 contain a perceptible amount of fluid, and I have repeatedly seen 
 them accidentally in post-mortem examinations, distended to
 
 OVAPwIAX TUMORS, CONDITIONS WHICH SIMULATE THEM. 165 
 
 the size of beans or filbert-nuts, and have disregarded them as 
 "Wolffian sacs," of no pathological importance. Some years 
 ago I had occasion to make a medico-legal examination of the 
 body of a woman far advanced in life, and I found in her left 
 broad ligament a cyst as large as an orange, filled with clear, 
 limpid serum. It was pressing upward and backward out of the 
 pelvis, the ovary being at its lower and anterior aspect, and the 
 Fallopian tube arched over its anterior surface. On the side next 
 the uterus two smaller cysts were lying close to it, and, nearer still, 
 a very minute sac, which was evidently, from its mere shape, a 
 distended parovarian tubule. The ovary was white, puckered, 
 and shrivelled, and had not a continuous relation to any of the 
 cysts, though it touched the largest at its hilum. The Fallopian 
 tube was normal, and had no other relation to the tumors than 
 slight connection by loose areolar tissue. There was in my mind 
 no doubt that this was a pathological indication of value; for in 
 an ovariotomy that I had performed not long before, I was struck 
 by the fact that the ovary was perfectly healthy and separated 
 from the tumor, as was also the tube, by a mesovarium of some 
 extent; in fact, I did not do ovariotomy at all in the removal of 
 the tumor; for, in passing the chain of the ecraseur round its 
 base, I did not include either the tube or the ovary, and they 
 were both returned into the abdominal cavity. In tlie records 
 of ovariotomies performed these cases have, up till now, always 
 been stated as ovariotomies, and the ovary and tube associated 
 with the tumor have been removed with it. Both the record and 
 the removal of the ovary are mistaken. The operation is not an 
 ovariotomy at all, and nine times out of ten both ovary and tube 
 might easily be separated from the tube and left, and this prac- 
 tice I now always try to follow. It is very curious that those 
 who are crying out most loudly against the unnecessary removal 
 of ovaries have been in the habit of pursuing this practice in 
 the case of parovarian tumors, without compunction. 
 
 The result of all my observations has been that in every truly 
 unilocular tumor I have found the ovary unaffected, though on 
 several occasions I have seen it stretched over the cyst- wall. I 
 liave three or four times observed the ovary separated from the 
 cyst by a more or less distinct mesovarium, and on one occasion 
 I found in that fold some unaffected parovarian tubules, in the 
 case of a lady, a patient of Mr. Hall-Wright, from whom I re- 
 moved a large unilocular cyst about six years ago. In another 
 instance the healthy ovary was left at least an inch below the 
 clamp; and in a third the ovary and tube were found glued on 
 to the cyst, but forming no part of it. In this cyst the walls 
 Avere extremely thick, and contained large quantities of involun-
 
 166 DISEASES OF THE OVARIES. 
 
 tary muscular fibre — a fact which I do not thinly militates against 
 my view that it was of parovarian origin; for nucleated muscu- 
 lar fibre-cells exist in the broad ligament to some considerable 
 extent, and myomatous tumors are found occasionally within its 
 folds. 
 
 The case to which I have alluded as presenting a tumor with 
 many cysts, but which ought to be placed under the same cate- 
 gory as the unilocular cysts, occurred in the person of a lady 
 aged sixty-six. She was a widow, having been married forty- 
 three years before the tumor appeared. The menses had ceased 
 for nearly twenty years, and her youngest child was twenty-five 
 years of age. There was every reason to believe, therefore, that 
 the condition of the cell-growth of her ovaries would be one of 
 very low activity. The tumor was first discovered about five 
 years before I saw her, and had grown slowly for four years and 
 a half, but with extreme rapidity for six months. The abdomi- 
 nal parietes were very thin, and the percussion-wave was com- 
 municated with extreme and uniform rapidity in every direction. 
 I diagnosed, from my former experience, that it was a unilocular 
 Wolffian cyst, and that the ovary would, in all probability, be 
 found uninvolved. I was right about the ovary, for that was 
 found, along with the tube, almost undisturbed, and not in any 
 way involved in the tumor, the latter having apparently escaped 
 from between them backward and upward. I had made a mis- 
 take, however, about the tumor being unilocular, for it was com- 
 posed of five or six sacs. The walls of these were very peculiar, 
 in being of uniform thickness, or rather thinness, for they were 
 like tissue-paper, and had no thickening toward the base of the 
 tumor, as is always the case in the multicystic adenoid or multi- 
 f ollicular tumor of the ovary. My belief is that this tumor was a 
 specimen of dropsy of a number of the parovarian tubules ; for, 
 if one alone may become dropsical, there can be no reason why 
 a number should not be so coincidently. My opinion has been 
 greatly strengthened, however, by a re-examination of the tumor 
 for the special investigation of one point drawn attention to by 
 Dr. Bantock; that is, the possibility of separating the outer or peri- 
 toneal coat of the cyst. This can readily be done toward its 
 base for a short distance up from the ovary, discovering the fact 
 that the gland and its duct can be stripped off the tumor without 
 damaging its wall. The rapid growth during the later periods 
 of its existence, however, seems to have so stretched the walls, 
 that, beyond two or three inches from its base, the peritoneal 
 layer cannot be separated from the cyst-wall proper. I have 
 quite satisfied myself that this case is really one of multilocular 
 parovarian tumor; and I am confirmed in this view when I find
 
 OVARIAN TUMORS, CONDITIONS WHICH SIMULATE THEM. 167 
 
 that Dr. Bantock refers to a case of Mr. Spencer Wells's, which 
 was recognized as one of bilocular parovarian cyst. 
 
 Considering this, it is a point for investigation whether or not 
 the curious little pedunculated cyst, representing the terminal 
 bulb of the Wolffian tube, and generally known as the organ of 
 Rosenmiiller, may not sometimes form a unilocular tumor of 
 morbid size, and be removed as an ovarian growth. In one case 
 I have removed it during an ovariotomy on account of increase 
 in its size. All these rudimental structures are lined with epi- 
 thelium, and may, therefore, conduct themselves as other struc- 
 tures so provided are known to do. 
 
 The diagnosis of parovarian cysts is generally very easy to 
 the practised hand, for they give a uniform and very rapid wave 
 of fluctuation in every diameter of the tumor. Their shape is 
 usually globular, but they do not project into the pelvis, as is 
 very often the case with the minor cysts of an ovarian tumor. 
 They very rarely give rise to symptoms of any kind, and still 
 more rarely to any symptoms of urgency. They sometimes grow 
 very rapidly. I removed a very large parovarian cyst some 
 years ago from a patient under the care of Dr. Campbell, of 
 Stourbridge, where the fact was fully ascertained that the tumor 
 grew in less than six weeks. It may happen, however, that all 
 the conditions of a parovarian cyst may be very closely imitated 
 by an ovarian tumor, and they are absolutely mimicked by two 
 rare forms of cyst to be afterward described, one of which is a 
 development of the occluded tube of the urachus, and the other 
 I believe to be developed from a wandering ovum. The fluid 
 removed from these cysts is often limpid, of low specific gravity, 
 containing little albumen. This, however, is by no means always 
 the case, for I have removed many parovarian cysts which 
 contained thick, gelatinous, grumous, or bloody fluid, which mere 
 tapping would never have led us to suppose had been produced 
 in any other cavity than that of an ovarian cystoma. At the 
 meeting of the Medical Society of Strasburg, November 15, 1875, 
 M. Koeberle read a paper on the diagnosis between ovarian cysts, 
 cysts of the broad ligament, and cysts of the Fallopian tube, 
 based on the chemical examination of the fluid contained in 
 them. He finds that the fluid of ovarian cysts contains some 
 albumen, but a much larger proportion of the variety of albumen 
 called paralbumen, the precipitate of which by nitric acid is 
 soluble in acetic acid. The fluid found in cysts of the Fallopian 
 tube, on the contrary, he says, contain albumen, but no paralbu- 
 men, so that the precipitate formed by nitric acid is rather in- 
 creased by acetic acid. The fluid of cysts of the broad ligament 
 is generally very limpid, containing salines, but no albumen.
 
 168 DISEASES OF THE OVAKIES. 
 
 Sometimes, however, it contains a small quantity of albumen, 
 and the precipitate formed by nitric acid may be soluble in an ex- 
 cess of that acid. The researches of Schutzenberger with the tan- 
 nin process for estimating the quantity and kind of albumen have, 
 however, thrown great doubt on these conclusions, and by the 
 same means I have quite satisfied myself that M. Koeberle"s con- 
 clusions are not to be accepted. At my request my friend Dr. 
 McMunn, of Wolverhampton, undertook to investigate the pos- 
 sibility of determining the source of fluids by means of the spec- 
 troscope. I furnished him with a number of specimens of fluid, 
 the sources of which were absolutely known, but the results of 
 his researches were entirely negative. They are given in detail 
 in his valuable work on •'The Spectroscope in Medicine"' (Lon- 
 don, 1880). There is an impression abroad that these cysts are 
 occasionally cured by tapping, but I am bound to say I have 
 never met with an instance of it. I have tapped many of them, 
 and I have seen them remain quiescent for a time — as long as 
 three years — and then rec^uire to be tapped again. In my recent 
 practice I have altogether discontinued tapping, and I invariably 
 remove them, the operation for their removal being simple and 
 easy, and in my hands it has been uniformly successful. 
 
 A further point of great importance in recognizing mere 
 ascites from an ovarian or parovarian tumor, is that in the for- 
 mer condition there is generally an appearance in the patient's 
 face of suffering from serious functional disturbance, whereas 
 in the latter the patient often looks in perfect health. Sometimes 
 we find the walls of a parovarian tumor very thin and flaccid, 
 in this way closely resembling the appearance of ascites. 
 
 This class of tumors it is which has given rise to a great 
 many different beliefs in connection with the history and treat- 
 ment of ovarian tumors Avhich Dr. Mathews Duncan has very 
 properly designated delusions. Among these was the belief, 
 originated by M. Boinet. that ovarian tumors had been cured by 
 tapping, by injection Avith iodine, by what Mr. Baker Brown 
 called a formation of a false oviduct by the insertion of setons, 
 and by a variety of other more or less barbarous and unscientific 
 proceedings. 
 
 The walls of these cysts are nearly always very thin, consist- 
 ing of little more than a thin basement-membrane and a lining 
 of columnar epithelium. This epithelium undoubtedly undergoes 
 alterations such as I have described as occurring in ovarian 
 cysts, for I have seen all the appearances on the lining of a par- 
 ovarian cyst that I have seen in an ovarian tumor. They un- 
 dergo malignant degeneration, they suppurate and become gan- 
 grenous just as ovarian tumors do. Sometimes the basement-
 
 OVARIAN TUMORS, CONDITIONS WHICH SIMULATE THEM. 169 
 
 membrane of their walls, which always contains some muscular 
 fibre, becomes enormously thickened, and I have removed a 
 parovarian cyst with walls more than half an inch thick, the 
 greater part of which was composed of fusiform muscular cells. 
 
 They are therefore not matters to trifle with. Their early 
 removal is always simple and safe. They should never be tam- 
 pered with by tapping, but ought to be removed by abdominal 
 section in their early stages, just as should ovarian tumors. 
 Sometimes they burst and seem to disappear spontaneously, and 
 this again has given rise to the statement that this result is ob- 
 tained occasionally for ovarian tumors. When this fortunate ac- 
 cident takes place early in their history it will probably do no 
 harm, but if it occurs during the advanced stages it is just as 
 likely to result in cancerous implantation of the peritoneum as 
 "if the cyst had been ovarian. A few months ago I removed a 
 large parovarian cyst which had several times been tapped, and 
 which had ruptured into the abdominal cavity. On removing it 
 I found the peritoneal surface studded with papilloma, of which 
 the patient has since died. 
 
 I have now to speak of that variety of cystoma to which I 
 have frequently referred as •' Rokitansky's tumor," or the multi- 
 ple cystoma. I am quite aware that both of these names are 
 open to objection, but I have failed to find any other more appro- 
 priate or descriptive. To Rokitansky is clearly due the credit of 
 having first described the tumor as a special variety of ovarian 
 cystoma, and to Ritchie must be accorded the priority of discov- 
 ering ova in its cysts; though, as I have already shown, the ob- 
 servation led him into a too hasty generalization. I think that 
 I may claim for myself the position of having first arranged the 
 various contributions into their proper positions, and from two 
 specimens I can now confirm and extend the observations of the 
 two authors I have cited. 
 
 These tumors are always double, no case having yet been 
 described as having occurred on one side only. They are always 
 of very slow growth ; their cysts are uniformly small, rarely 
 reaching the size of an orange, and generally being little bigger 
 than grapes. The tumors are never large, and it is only the fact 
 that both ovaries are always affected that makes them objects of 
 surgical interference. The contents of the cysts are invariably 
 limpid, and the ovum may nearly always be found, and in these 
 two respects, as well in the immense number of the cysts, the 
 tumors differ absolutely from ordinary cystoma. 
 
 The first case occurred in the person of a hospital patient from 
 whom I removed both ovaries. Both tumors were multilocular, 
 and had one or two major with innumerable minor cysts, gradu-
 
 170 DISEASES OF THE OVARIES. 
 
 ating down to the most minute size. The fluid contents of all 
 were limpid, and what was evacuated from three or four cysts 
 at the time of the operation, together with the solid masses of 
 both tumors, did not weigh quite ten pounds. The right tumor 
 seemed to be about one-fourth larger than the left, so that they 
 were probably four and six pounds in weight respectively — small- 
 sized tumors. Both pedicles were included in one clamp, and 
 the patient made an uninterrupted recovery. 
 
 After removal, the most careful examination of the tumors 
 failed to discover any remnant of the ovaries outside them, nor 
 did I find any trace of either of the Fallopian tubes, as I had not 
 removed them. The tumors were pearly white and glistening; 
 but the thin parts of the major cysts had a peculiar transparency 
 that I had never noticed in any other tumors before, and colum- 
 nar bands stood out here and there in relief on the walls. I may- 
 say that the tumors had been of extremely slow growth; for I 
 had had the patient under notice for nearly a year before the 
 operation, and had not discovered any increase in the size of the 
 tumors, though they had been in existence probably five or six 
 years. 
 
 The interiors of the large cysts were lined with regular col- 
 umnar epithelium, and the wall seemed composed of fibrous tis- 
 sue with some nucleated almond-shaped cells. The smaller cysts 
 were densely packed together, and at some places, where they 
 were of a uniform size, the tumors had much the appearance of 
 huge white raspberries. I was struck with the resemblance the 
 tumors presented to what I recollected of those in which Roki- 
 tansky and Ritchie had found ova. and I at once turned to Dr. 
 Ritchie's admirable monograph, and found that the tumors an- 
 swered the descriptions completely. I therefore examined the 
 contents of as large a number of the cysts as I could, and in 
 every one — I think without exception — I found more or less dis- 
 tinct evidence of an ovum. 
 
 It will serve my purpose best to quote at length from Dr. 
 Ritchie's book — for our experiences are almost identical — and he 
 also gives the observations of Rokitansky. 
 
 " In the first volume of the Wochenhlatt der Zeitschrift der 
 K. K. Qesellscliaft der Aerzte zu Wien, Rokitansky describes 
 the appearances observed in the post-mortem examination of a 
 woman, twenty-six years of age, who died with diseased ovaries. 
 Both ovaries were affected. The tumor on the right side was as 
 large as a child's head, that on the left as large as a man's fist. 
 Both ovaries were composed of a number of cysts as^ large as a 
 cherry, which for the most part lay closely packed together, here 
 and there had become flattened by mutual compression, and oc-
 
 OVARIAN TUMORS, CONDITIONS WHICH SIMULATE THEM. 171 
 
 casionally even projected into each other. The surfaces of the 
 tumors were thus slightly lobulated, and between the protuber- 
 ances were seen, at intervals, cysts as large as a barleycorn, a 
 pea, or a bean. These latter cysts, on being punctured, gave 
 exit to a greenish-colored fluid containing membranous flocculi, 
 and in all of them the ovum was found. In each of them, how- 
 ever, the ovum was softened, very dull-colored, easily disinte- 
 grated. The zona pellucida had for the most part lost its sharp 
 contour, and, except in one case, no germinal vesicle was dis- 
 coverable. 
 
 ' ' As far as I am aware, this observation of Rokitansky was 
 never publicly confirmed until July, 1864, when the reporter to 
 the Medical Times and Gazette of four cases of ovariotomy, per- 
 formed by Mr. Spencer Wells in the Samaritan Hospital, men- 
 tioned that, in two of the tumors removed. Dr. Webb and myself 
 had been fortunate enough to discover many ova. 
 
 " The patient from whom the tumors in question were re- 
 moved was fifty-four years of age, and had been for some time 
 suffering from double ovarian disease. The tumors were easily 
 extirpated, and the patient recovered. Each tumor was of the 
 size of the head of a child four years of age. Each contained 
 several large central cavities, and a number of smaller ones in 
 the wall of the central cavity, the wall itself never exceeding 
 one inch in thickness. In the Medical Times and Gazette for 
 August 6, 1864, Mr. Spencer Wells wrote as follows: 
 
 *' 'The two tumors in question were examined directly after 
 their removal by Dr. Ritchie, who pointed out to me, in each of 
 them, a number of small cysts, which were evidently enlarged 
 Graafian follicles. Knowing the great and long familiarity which 
 Dr. Woodham Webb has had with the ova of various species of 
 animals since his researches in conjunction with Barry, I asked 
 him to examine some of the cysts, in order to ascertain whether 
 they did or did not contain ova, knowing that on this point no 
 higher authority could be appealed to. 
 
 " 'As one friend has suggested that we may have mistaken 
 a blood-corpuscle for an ovum, there was evidently some reason 
 for my caution; but I trust that the following note from Dr. 
 Webb will set all such doubts at rest: 
 
 '* ' " Both the tumors you sent me, after their removal from a 
 woman fifty-four years old, were growths in excess of true ova- 
 rian structure. The multilocular character was produced by 
 clusters of ovisacs of various sizes. Ova, with the other natural 
 contents, were to be found in all the small sacs. The fibrous 
 coats of the larger sacs were thickened, and had many other 
 secondary sacs developed in them. The interior was lined with
 
 172 DISEASES OF THE OVAKIES. 
 
 epithelium, which in some instances had, by parthenogenetic 
 enlargement and successive budding of the cells, given rise to 
 bunches of grape-like growths, repeated generations of imperfect 
 ova."' 
 
 '• • The whole, then, was nothing more than a reproduction in 
 the human subject of conditions which are natural in some of the 
 lower creatures. I suppose the description, in your orthodox 
 pathological terms, would be, " hypertrophy of the ovaries, with 
 arrested development of the contents.'' ' 
 
 •• This letter, coming from a gentleman of Dr. Webb's known 
 experience, is of great interest. Dr. Webb evidently inclines to 
 the belief that the ovum is only an altered epithelium-cell. He 
 also seems to believe that the grape-like growths — those de- 
 scribed farther down as dendritic growths — are repeated genera- 
 tions of imperfect ova." 
 
 Dr. Ritchie's unfortunate death, and my want of acquaintance 
 at that time with Dr. Webb, hindered me from becoming ac- 
 quainted with their method of manipulation; but that which I 
 devised for myself answered my purpose completely. It consists 
 in slitting open the cyst freely with a cataract-knife over a coni- 
 cal glass, collecting the whole contents, and afterward syringing 
 out the cavity of the cyst gently with a solution of sulphate of 
 magnesia in distilled water of a density something near that of 
 the cyst contents. The fluid with which the cyst is syringed out 
 is allowed also to fall into the vessel, and the whole to stand for a 
 few hours, at the end of which time a little flocculent sediment 
 will have collected at the bottom of the vessel. This is to be 
 carefully lifted by a pipette, deposited in a clean watch-glass, 
 and the ovum searched for under the microscope. What I found 
 in every case I could not, of course, assert was an ovum; but 
 having found one or two specimens about wiiich there could be 
 no doubt, and in every case something that was more or less 
 like one, I am perfectly satisfied that in those tumors every cyst 
 was a dilated ovisac. The smaller the sac, the more perfect the 
 ovum seemed to be, and consequently I assumed that these were 
 the more recent growths. Not only were these dilated ovisacs in 
 the periphery of the tumors, but they were found throughout its 
 substance. In fact, it seemed to me as if, for a long period of her 
 ovarian history, the ova had been garnered up in cysts instead 
 of being shed in the usual manner. Her youngest child was six 
 years old, and if we were to assume that an ovum is shed from 
 each ovary monthly, then we should get the number of ova so 
 retained as about one hundred and fifty. The number of cysts 
 was, however, much greater, probably two or three times as 
 many; so that we may choose between two explanations — either
 
 OVARIAN TUMORS, CONDITIONS WHICH SIMULATE THEM. 173 
 
 that the tumors had existed before her last pregnancy, or that 
 more than two ova are shed in the month. My own behef is. 
 that both these suppositions are correct; for, when speaking of 
 ovulation at the beginning of the essay, I gave reasons for my 
 belief that ovulation and menstruation had only a connection of 
 concurrence. I am of opinion that ovulation takes place far 
 more frequently than menstruation does. 
 
 It is a somewhat singular fact that the observation of Roki- 
 tansky has not been confirmed, as far as I have yet seen, by any 
 others than Ritchie and Webb, and by my own cases. Still 
 more curious is it that all four cases are almost identical, pre- 
 senting small multilocular tumors of slow growth, and that in 
 all four cases both ovaries were affected. This inclines me to 
 believe that in these cases we have to deal with a special kind of 
 ovarian tumor, occurring rarely and differing from the ordi- 
 nary adenoid growth. Whether this be so or not, further expe- 
 rience alone can show. Dr. Ritchie says, immediately following 
 the quotation I have given above, that he subsequently suc- 
 ceeded in finding ova in some of the loculi of a large number of 
 ovarian cysts, but never in a loculus larger than a cherry, nor 
 in one that had jelly-like contents. This observation I cannot 
 confirm; for, though I have made many searches in the endo- 
 genous and subjacent secondary cysts of ordinary polycystic 
 tumors, I have never found an ovum or anything resembling 
 one. Perhaps my method is defective. Dr. Ritchie further 
 says that, when no ovum is to be found, a single minor cyst i& 
 to be seen, embedded in one part of the wall, and he has 
 thought himself justified in concluding that this appearance 
 represents dropsy of the blastodermic vesicle. I have certainly 
 seen such vesicles in the walls of small cysts, but I have as often 
 found them multiple as single, and I have never seen reason to 
 interpret them as Dr. Ritchie has done. 
 
 The second case of the occurrence of this i:>eculiar form of 
 tumor was that of a patient sent to me by Dr. McVeagh of 
 Coventry in December last. The tumor had been noticed for 
 two years, and had been increasing somewhat rapidly for seven 
 months. I had no doubt as to the diagnosis of an ovarian 
 tumor, but there was something in the examination that made 
 me fear it was malignant. The patient was thin and looked 
 very ill, but j^et had no particular symptoms, and the distention 
 of the abdomen was not great — that is, the tumor was not very 
 large. I operated on December 7tli. and when I opened the ab- 
 domen I found a large mass of glistening cysts of a pearly white 
 lustre, varying in size from a pea to a small orange. The omen- 
 tum was inextricably mixed up with them, so that at first sight
 
 174 
 
 DISEASES OF THE OVARIES. 
 
 I was under the impression I had made a mistake and had to 
 deal with a case of hydatids of the peritoneum. I found, how- 
 ever, that the mass was removable and that the cysts were pe- 
 diculated upon a common stem. To get the mass out of the ab- 
 domen was a matter of no 
 small difficulty, and to 
 accomplish it I had to 
 make an unusually large 
 incision, nearly seven 
 inches long. Then I found 
 that the stalk of the tumor 
 reached toward the left 
 cornu of the uterus, and 
 that as the left ovary could 
 nowhere be found the tu- 
 mor must represent it. I 
 tied the pedicle and re- 
 moved the mass ; I then 
 looked for the right ovary, 
 but could nowhere find it, 
 but loose in the abdomen 
 I found a smaller mass of 
 cysts which I think must 
 have been the missing 
 gland. How it came to be 
 separated from its stalk I 
 do not know. During the 
 operation several of the 
 cysts had become detached 
 from the common stem by 
 rupture of the slender peti- 
 oles, and I had to hunt 
 carefully about among the 
 intestines to make sure 
 that I left none of them. 
 The patient made an excel- 
 lent recovery, and is now 
 in perfect health. 
 
 The adjoining illustra- 
 tion, which is taken from 
 a photograph, will give a better idea of the appearance of the 
 tumor than any description. On the right side and hanging down 
 from the mass may be seen the omentum, nearly the whole of 
 which was removed with the tumor, and through the meshes of 
 which many of the cysts seem to have grown. It is adherent 
 
 Fig. S8. — Rokitansky's Tumor, each ryst containing an 
 ovum : from a photo^rraph by Thnipp. about on^-third of 
 actual size. Preparation ni Hunterian Museum of Royal 
 College of Surgeons.
 
 OVAKIAN TUMORS, CONDITIONS WHICH SIMULATE THEM. 17o 
 
 here and there, but its association with the tumor seems to be 
 more that it is involved with the growth in a sort of mesh- work, 
 than as having the ordinary form of adhesion. Everywhere the 
 curious small cysts with their slender pedicles may be seen hang- 
 ing like grapes upon their stalks, and at the upper part of the 
 tumor may be seen some of these pedicles branching and having 
 cysts attached to them exactly like leaves upon their stalks. In 
 this respect it differs somewhat from the first case I have de- 
 scribed, but at other parts of the tumor the resemblance is close, 
 and microscopical investigations gave exactly the same results as 
 those above described. Save in the very largest cavities which 
 had been emptied in order to facilitate the removal of the tumor, 
 I found a normally columnar epithelium, and normal or nearly 
 normal ova. In the small cysts the appearances were precisely 
 those seen in Graafian follicles. The tumor is now in the mu- 
 seum of the College of Surgeons, and I trust that any one meet- 
 ing with a similar example will secure for it a most careful ex- 
 amination. 
 
 Partaking of the nature of the cysts last described, to some 
 extent and in some way yet inexplicable, are the mysterious pro- 
 ductions known as dermoid cysts. The term " dermoid" is not 
 a good one, for it by no means gives expression to a constant 
 character of these tumors. Sometimes there is no trace of any 
 epithelial products at all; while we find bones, muscle, and 
 brain-substance even, according to Beneke, in some of them. 
 The name, however, is hallowed by tradition, and it is not easy 
 to coin a better one. 
 
 I have already explained at some length, and I hope success- 
 fully, my view that Rokitansky's tumor is produced by the re- 
 tention of the ova in the Graafian follicles and the distention of 
 their cavities by a continuous secretion of the liquor folliculi. 
 My theory of the production of dermoid tumors is that they are 
 the result of a growth of the ovum itself. 
 
 That these tumors are the result of change in an ovum is 
 about the only part of their history regarding which there can 
 be any certainty. But there may be doubt as to whether the 
 abnormality takes origin in an ovum of the individual bearing 
 the tumor, or in the ovum from which she herself was developed: 
 in other words, whether the tumors are abnormally developed 
 ova or are due to inclusion. That they have any origin in im- 
 pregnation, we may at once dismiss as excluded from serious 
 consideration, since they have been frequently found in newly 
 born children, and their most common seat is in the ovaries of 
 young women, chiefly, according to Mr. Spencer Wells, of fair 
 complexion.
 
 176 • DISEASES OF THE OVAKIES. 
 
 The question of their origin, then, lies between the hypothe- 
 sis of an effort on the part of some over-active ovum in the di- 
 rection of parthenogenesis, which has been based by Dr. Ritchie 
 on Blumenbach's less scientific and more scholastic expression 
 of " excess of formative nisus," and the equally hypothetical 
 process of inclusion. As far as we know anything about inclu- 
 sion, it follows the usual law of teratology, that any attached 
 individual, whether developed or blighted, is symmetrically con- 
 nected. Thus the Siamese Twins and the Millie-Christie mon- 
 strosity have the attachment in similar and identical structures, 
 the one to the other (see Vrolik, Von Baer, etc.). I have seen 
 nowhere on record that any fetal remains have been found at- 
 tached to an ovary, or situated in an ovary in any way whicli 
 could find them a classification under this law. The tissues met 
 with are always rudimental, and such as, while they are the 
 product of the ovum after conception, have no anatomical anal- 
 ^Sy whatever to tlie tissues of the ovary. I am disposed, there- 
 fore, to set aside entirely the view of their origin by inclusion, 
 as the ovary is about the most unlikely structure in the embryo 
 for such a process; and, if they had their origin in such a way, 
 we ought to find dermoid cj^sts in tlie testicles of the male quite 
 as often as in the ovaries of women. 
 
 There is only left, then, the explanation that dermoid cysts 
 are the result of an altered nutrition of one or more ova; and, if 
 I may lay down a dogma from my own dissections, I should say, 
 of one ovum only. Dermoid cysts are generally unilocular, and, 
 when they are not so, it is not difficult to show, as has been 
 done by Dr. Ritchie, and has been evident in one or two speci- 
 mens that I have examined, that the secondary cysts are formed 
 by the mother cyst being partitioned off by the growth of ridge- 
 like walls on the inside of the cyst. 
 
 The occurrence of cysts having a structure somewhat re- 
 sembling the dermoid cysts of the ovary in other parts of the 
 body, especially in the neighborhood of the orbit, has led to con- 
 fusion in the discussion of the origin of the ovarian cysts. In 
 the orbital cysts we have only aberrations of the normal process 
 of the involution of epithelium from which the structures are 
 developed, and there is no mention, as far as I can find, of these 
 extremely small congenital cysts, which never enlarge in after 
 life, having been found to contain anything but purely epithelial 
 products, such as hair, dead epithelial cells, and fat. In dermoid 
 cysts of the ovary, however, the variety of products is so great, 
 as to put all analogy between them and inclusive cysts out of 
 the possibilities. Thus, in one ovarian cyst which I examined 
 under the direction of my friend and teacher. Dr. Grainger
 
 OVARIAlSr TUMORS, CONDITIONS WHICH SIMULATE THEM. 177 
 
 Stewart, many years ago, in the substance of a wall between 
 two loculi, were spread out flat bones which were undoubtedly 
 some of the bones of the skull, and near them could be felt the 
 representatives of the bones of a limb arranged in order. True 
 bone is frequently found in ovarian cysts, and often in those 
 that have no dermoid structures at all. 
 
 Sir James Paget refers to a remarkable specimen in the mu- 
 seum of St. George's Hospital, which exhibits a mass of fatty 
 matter and a lock of dark hair, one and a half or two inches 
 long, attached to the inner surface of the dura mater at the tor- 
 cular Herophili, found in a child two and a half years old, in 
 whom it appeared to be congenital. He adds, in a foot-note, 
 that Dr. John Ogle, who had carefully examined the specimen 
 and described it to the Pathological Society, was of opinion that 
 the cyst was originally of extracranial formation, but that, at an 
 early period of fetal life, before ossification of the occipital bone 
 had taken place, the cerebral membranes and scalp had become 
 adherent, and that, as the development of the bone went on, the 
 outer integument was drawn in by retirement of the cerebral 
 membranes. In this way some of the cutaneous structures had 
 become included within the cranium. He considers that the 
 cyst possesses characters which warrant the above supposition, 
 and he adds that, in a similar manner, cysts within the orbit 
 may extend into the cranial cavity. No such explanation could 
 include the phenomena of the ovarian tumors which contain 
 such structures as teeth, bone, cartilage, striped muscular fibre, 
 brain and nerve tissue, etc. The true solution can be found only 
 in a hypererchetic development of an ovum, a cell which has in 
 it the power of formative origin for all these structures. The 
 process of growth of the ovum after impregnation can be fol- 
 lowed only after the assumption, either expressed or uncon- 
 sciously accepted, of such a hypothesis as is contained in Mr. 
 Darwin's "Pangenesis." The germ contributed by the male 
 contains, we knew only too well from pathological experience, 
 gemmules having certain powers and functions; and we may 
 therefore assume, as indeed we also know, that the female germ 
 contains also such gemmules. It may be that the ovum has in 
 it the origin-buds of certain tissues, and that, under exceptional 
 hypererchetic action, they may go on to the rudimental forma- 
 tion of these tissues without a fusion with the male germ. More 
 careful and accurate description of what is found in dermoid 
 cysts may help to solve this riddle; still better, perhaps, a care- 
 ful consideration of what tissues are not found in them. 
 
 This doctrine of hypererchesis is supported by many facts 
 which have been observed in cases where the changes in the 
 12
 
 178 DISEASES OF THE OVARIES. 
 
 ovum can be watched outside the body of the parent. Thus Bis- 
 choff and Leuckhart have both described partial development of 
 ovules which have been placed beyond the possibility of impreg- 
 nation. Dr. Moquin-Tandon has, more recently (1875), described 
 analogous facts before the Academic des Sciences, among 
 which he gives details of the process of segmentation in the ova 
 of a frog which had been kept in confinement for four months. 
 
 There were first noticed two large vertical fissures in the 
 ovule, followed soon by similar horizontal segmentation, and 
 this process of division proceeded further, but in a less regular 
 manner than usual, the yolk spheres multiplying irregularly, 
 and becoming of unequal size, and it was more rapid than in 
 fecundated eggs which were allowed to develop at the same 
 temperature. Only a small number of the ova presented this 
 evidence of commencing development, for the majority died 
 without any sign of segmentation. Sometimes death occurred 
 after the division into two or four segments, sometimes at a 
 more advanced period, but the ovule never assumed the mul- 
 berry appearance. The author considers that this incontestably 
 proves that the ova of vertebrata, not impregnated by sperma- 
 tozoa, may pass through the earliest stage of development in 
 certain conditions, the exact nature of which is at present un- 
 known. It seems to me that we may take this process to be 
 exactly what occurs in the development of the spore of the fern 
 into the prothallus, and the tendency which these unfertilized 
 ovules have to this primitive and ineffectual development is 
 derived from the continuity of descent. In the insecta the pro- 
 cess is carried much further, for Balbiani exhibited some eggs 
 of the silkworm moth to the Societe de Biologic (1873), which 
 had been deposited before fecundation could have been effected. 
 A certain number of these eggs remained sterile, but others 
 showed signs of development, though in no instance had the 
 larva escaped from the egg. The number of these developing 
 eggs varied extremely according to the species of moth by which 
 they were deposited. The largest number was met with in 
 those which produce several generations per annum. Among 
 9,000 eggs of a polyvoltine race, 513 developed spontaneously; 
 while of 50,000 of an annual race, 29 only were fertile. M. Bal- 
 biani thinks that this enormous difference is probably due to the 
 feeble vitality of the egg in the annual races, a suggestion which 
 cannot be considered in any way as an explanation; neither can 
 his idea be entertained that the parthenogenetic development is 
 to be accepted as proving the hermaphroditism of the egg, for 
 there is no evidence whatever of such a condition. What has 
 been observed by Balbiani is indeed only an attempt to fulfil the
 
 OVARIAN TUMORS, CONDITIONS WHICH SIMULATE THEM. 179 
 
 conditions seen in the aphides, where the cell multiplication in 
 the pseiidovaria produce a new individual without any sexual 
 congress. Putting these facts along with others observed by 
 Agassiz and Burnette in fish, by Hensen in the rabbit, by Bis- 
 choff in the sow, and more especially the remarkable observa- 
 tion of Oellacher, that segmentation occurs in the eggs of fowls 
 kept from the cold, while the eggs are still in the oviduct, I do 
 not think that there is any difficulty in believing that the hyper- 
 erchetic efforts of the human ovum which result in the forma- 
 tion of those so-called dermoid cysts, are parthenogenetic, and 
 have originated in the early phases of our ancestry. In the 
 human ovary these processes are carried further by an abun- 
 dant blood-supply. 
 
 Sir James Paget has, it seems to me, struck the key-note of 
 the pathology of dermoid cysts when he wrote, " It is, perhaps, 
 only during the vigor of the formative forces in the fetal or 
 earliest extra-uterine periods of life that cysts thus highly organ- 
 ized and productive are ever formed." A most important point 
 in the pathology hangs on this sentence, and can be decided 
 only by a determination of the age at which such tumors are 
 most frequently found. It is, of course, evident that the ages at 
 which these tumors are removed by the operating surgeon can- 
 not be taken into account, as they are of slow growth, and have 
 often been recognized as being present for many years without 
 perceptible increase. They are quite unlike, in this respect, the 
 ordinary adenoid tumors. Their contents even show that their 
 existence must often have been contemporaneous with the life 
 of their bearers ; for w^e find large balls of hair, the result of the 
 epithelial growth and shedding of a nipple-like process not 
 bigger than the tip of one's finger; and in one sac over three 
 hundred teeth have been found, resembling, in many respects, 
 milk-teeth; so that we may reasonably suppose that they were 
 the repeated products of a limited dentigenous area. In one of 
 Mr. Spencer Wells's cases, the preparation of which is in the 
 Hunterian Museum, a piece of bone was found resembling 
 greatly a part of the upper maxilla and sphenoid bones, and con- 
 taining mature molar teeth. In fact, inspection of the specimen 
 almost carries conviction to the mind that the bone and tooth- 
 sacs were produced at an early, perhaps intra-uterine, period of 
 the life of the patient, and that they grew and matured as she 
 did till the tumor was removed, at the age of thirty-nine. 
 
 Dermoid and dentigenous cysts have been so frequently 
 found in children, that it may be suspected that if the histories 
 of all such as are removed by operation could be traced, they 
 would be found to be, as Paget suggests, either congenital or
 
 180 DISEASES OF THE OVAEIES. 
 
 originating very early in life. Indeed, it seems to me to be im- 
 possible that it can be otherwise when we remember how soon 
 after birth all processes of development must cease, and those of 
 growth alone are continued; impossible that new tissues, so 
 strange and displaced, should be developed after the formative 
 powers have ceased to produce new tissues in normal positions. 
 The more we know of pathology, the more we find its processes 
 resemble those of physiology; and it seems to me far more 
 simple to explain the occurrence of dermoid cysts in the ovary 
 by hypererchetic action of an ovum at the time of life when 
 such processes are in vogue in the economy, than at some other 
 time when they have entirely ceased everywhere else. I have 
 already shown that the formation and destruction of ovarian 
 cells goes on from the earliest to the latest times of existence, 
 the degree of their maturity varying with the periods of life. 
 Fully dilated Graafian follicles are often seen in the ovaries of 
 newly born children, containing ova which are minute, trans- 
 parent, and structureless cells. But let us suppose that, during 
 the developmental period of life, some stimulus be given to one 
 Graafian follicle and its contained ovum, which for want of 
 better knowledge we may call accidental, and that this should 
 lead to the premature maturation of the ovum, so that, w^ere the 
 rest of the organism ready for the process, it might be carried 
 into the uterus and there be impregnated. Let us further sup- 
 pose that, instead of being destroyed by rupture of the ovisac, it 
 should remain in the ovisac and share alike with the rest of the 
 economy in developmental activity, there could be only one re- 
 sult, and that would be the formation, to an incomplete degree, 
 of those structures which it would evolve in perfection under 
 more favorable conditions. 
 
 In support of my supposition, I may draw attention to a de- 
 scription further on of a dermoid cyst which I found in the peri- 
 toneum with attachments to its surface, but without connection 
 to either of the ovaries. This tumor was so intimately and so 
 extensively adherent to the peritoneum that I had to leave it, 
 and I had reason to believe it had no ovarian connection. Might 
 not such be developed from an ovum which had escaped from 
 the ovaries in early life, and become attached to the peritoneum, 
 as we know they do in after life, and there have carried on its 
 attempt at parthenogenesis ? 
 
 The logical conclusion of this view is, that if such an ovum 
 could get into the uterus after its escape, it would develop into 
 a perfect instance of parthenogenesis — a speculation, of course, 
 but no wilder than some of the facts of embryology seemed to us 
 before we understood them. It is in fact quite analogous to the
 
 OVARIAN TUMORS, CONDITIONS WHICH SIMULATE TIIEM. 181 
 
 production of the aphis by a virgin and sexless larviparous 
 mother. 
 
 Whatever may be the vahie of the suggestions I have thrown 
 out, they are certainly consistent with my own clinical experi- 
 ence; for in one case where I removed a dermoid cyst from a 
 young woman, there were many reasons for believing that it 
 had existed long before puberty. The oldest patient from whom 
 I know that a dermoid cyst has been removed is a case of my own, 
 the woman being in her forty-fifth year. The tumor weighed 
 only six and a half ounces, and was full of hair, which had 
 grown and been shed from one little spot of skin not bigger than 
 the tip of my little finger. The amount of hair in the sac, had 
 it grown from a similarly sized area of scalp, would have taken 
 almost a lifetime to grow and be shed. In Mr. Wells's oldest 
 case (38), the tumor had been recognized for eighteen years; 
 and in a case (37) not operated upon, but examined after death, 
 the tumor had been known to be in existence for at least twelve 
 years. The usual age for dermoid cysts to come under the 
 notice of the surgeon is from seventeen to twenty years, and 
 then it is generally certain that they have been long in exist- 
 ence. After puberty, the recurrent congestion of the whole sex- 
 ual apparatus must stimulate into growth what is in readiness 
 for it after having been developed long previously, as I have 
 suggested in my hypothesis. The results of that development 
 may remain of minute or even microscopic size, until the stimu- 
 lus of the menstrual hypersemia so increases them as to make 
 them of surgical importance; just as Hunter's celebrated experi- 
 ment of the transplantation of the spur of the cock into his 
 comb resulted in an extraordinary increase in length and size of 
 the spur by the altered character of its haemic nutrition. Occa- 
 sionally, however, the}' grow to a large size before puberty. 
 
 At a meeting of the Pathological Society of London, on Tues- 
 day, May 5, 1874, Dr. Dickinson showed an ovarian tumor re- 
 moved from a child, aged ten, at the post-mortem examination. 
 About twelve months previously the child complained of pain in 
 the right side, and lower part of the abdomen, and then a small 
 swelling the size of an egg was noticed. In six months' time 
 this was as large as a small apple. It then rapidly increased. 
 When first seen the umbilical girth was twenty-five inches, and 
 she was in much pain. The diagnosis was difficult, and it was 
 at first supposed to be a malignant growth of the kidney. She 
 was removed from the hospital, and on her return, some months 
 after, the umbilical girth was twenty-seven and one-half inches. 
 She died soon after of peritonitis. A tumor of the right ovary 
 was found, weighing five and one-half pounds. It contained
 
 182 DISEASES OF THE OVARIES. 
 
 hair, bones, etc. All the other organs of the body were healthy. 
 The child had never menstruated. An exploratory incision 
 would probably have saved this child's life. 
 
 Briefly, then, I believe dermoid cysts to be the result of hy- 
 phererchetic development of an ovum in fetal Or infantile life, 
 growing into a tumor during and subsequently to puberty. 
 They are always invested by the ordinary peritoneal covering of 
 the ovary, beneath which is a more or less thick layer of the 
 nucleated and banded fibrous tissue, which forms the basis of 
 all ovarian cysts. I have seen this layer as thin as tissue paper, 
 and in one old-standing dermoid cyst it was more than an inch 
 thick, and occupied by large plates of calcification. In it are to 
 be found the same almond-shaped nuclei which characterize the 
 stroma of the ovary, only they are sparsely distributed, as I have 
 already said they always are in old tumors. Within this layer 
 the peculiar structures met with in dermoid cysts occur, an ar- 
 rangement strongly indicative of the method of origin which I 
 have suggested for them. I do not know of any tissue in the 
 body which may not find its representative in them, for Beneke 
 has even found brain-substance. Usually, however, they have 
 an epithelial character, and in some instances show great ad- 
 vance both in development and growth. When skin or mucous 
 membrane is present, all the details of their structure may be 
 made out; and as there is no vasomotor check on the vascular 
 supply, the materials which they secrete normally are often 
 found in vast quantities, as, for instance, hundreds of teeth, and 
 pounds of sebaceous matter. 
 
 Another kind of tumor, undoubtedly of ovarian origin, though 
 ■without the appearance of any relation to the ovary save that of 
 contiguity, has several times come under my observation, and 
 as I have met with no description of a precisely similar case, 
 I am induced to place on record a full description of it. The first 
 case was in a patient, thirty-seven years of age, who was placed 
 under my care by Dr. Blackwood, of Wednesbury, who had at- 
 tended her in three confinements, the first of which was natural, 
 the second had to be completed by the use of forceps, and in the 
 third version had to be performed on account of obstruction. 
 The last labor occurred in 18G9, and after that till the time I saw 
 her, April, 1873, menstruation occurred normally. During that 
 time a protrusion from the vulva gradually formed, and when 
 first seen by Dr. Blackwood it had reached an enormous size, 
 and included the uterus, bladder, and rectum, and it had become 
 perfectly irreducible. Dr. Blackwood also discovered a large 
 abdominal tumor, which seemed to be the cause of the protru- 
 sion. I found that this tumOr extended to about. four inches
 
 OVAEIAX TUMORS, COXDITIOXS WHICH SIMULATE THEM. 183 
 
 above the umbilicus, that it filled the pelvis, and the character 
 of the fluctuation made it apparent that it was a unilocular cyst. 
 It was very much fixed in the pelvis, so that I gave the opinion 
 that it was adherent, and that probably much difficulty would 
 be encountered in its removal, but as its growth had been rapid 
 I advised an exploratory incision. This I made in the usual 
 way on April 27th, but could find no line of demarcation between 
 the peritoneum and the cyst-wall. The latter was very much 
 thickened, and on being cut through it was seen to contain a 
 large number of hairs, not growing into the cyst, as is usually 
 the case, but growing merely in the wall, for not a hair was to 
 be found free on the inner surface of the cyst. The contents 
 consisted of clear serous fluid, in which floated long processes of 
 translucent membrane, exactly resembling the omentum of a 
 foetus; and there was also one long finger-like process of pure 
 fat, encapsuled in serous membrane. The sac was emptied of 
 everything, and attempts were made on every side to discover a 
 division between it and the peritoneal cavity. Above, I dis- 
 sected till I found that its union with the intestines was so inti- 
 mate as to render its removal impossible. On each side it 
 seemed to be entirely continuous with the abdominal walls as 
 far as the brim of the pelvis. Below it, the uterus and ovaries 
 were felt to be quite free, so that it was made certain that the 
 tumor was not ovarian, and behind it the intestines could be felt 
 in a cavity which probably extended down to Douglas's pouch. 
 When these details had been made out, it became quite evident 
 that the proper treatment for this anomalous case was to close 
 the wound, save at its lower angle, where a drainage-tube was 
 placed; but before I did so, I removed a fragment of the wall of 
 the cyst in which I had noticed the hairs. I need not give a de- 
 tailed account of her progress toward recovery, more than to say 
 that the cyst suppurated freely, and that the suppuration slowly 
 diminished, so that in July I removed the drainage-tube. In 
 October there still remained a slight discharge from the site of 
 the drainage-tube, all tendency to protrusion from the vulva had 
 ceased, and it could be felt that the roof of the pelvis was some- 
 what fixed and the uterus retroverted. The wound also was 
 slightly drawn inward, but there was no other trace of the tumor. 
 The patient now (1880) enjoys robust health, and still menstru- 
 ates regularly. 
 
 Examination of the fragment of the cyst-wall which I re- 
 moved showed that hairs were growing in it, or at least existed 
 in it, in large numbers, and that they all lay in a direction par- 
 allel to the cyst-wall. There were also traces of rudimentary 
 skin structures, as papillae, fat loculi, and something like glands,
 
 184 DISEASES OF THE OVARIES. 
 
 quite sufficient to place this remarkable tumor within the cate- 
 gory of dermoid cysts; and in this direction also the serous mem- 
 brane found within it pointed. What, then, was its origin ? In 
 answer to this, only two suppositions can be entertained, the 
 first and least likely of which is that it was an inclusion cyst, 
 similar to that already referred to as situated at the Torcular 
 Herophyli. The other, and I think that which must be accepted, 
 is that it had grown out of a wandering ovum, which, after its 
 escape from its Graafian follicle, had failed to be extruded in the 
 ordinary way, had not died, but had gone on to a hypererchetic 
 development. 
 
 We know that ova are sometimes matured in infantile, even 
 in embryonic life, and also that they sometimes undergo this 
 hypererchetic development in the ovary. In adult life, we also 
 know that all the ova which escape from the follicles do not 
 reach the uterus, and it is more than probable that a large num- 
 ber of them escape into the peritoneal cavity, and there wander 
 till they die. As the ovum when impregnated fixes itself at once 
 to the surface with which it is at the time in contact, and there 
 develops, so it is not impossible that one of these hypererchetic- 
 ally inclined ova, having escaped into the peritoneal cavity, 
 there becomes adherent, and grows into such a dermoid cyst as I 
 found in Dr. Blackwood's case. All the circumstances necessary 
 for this coincidence being rare, of necessity its results will be 
 rare; but as our surgical experience of such matters is just, as it 
 were, beginning, such a case as the one I have narrated may not 
 be without a parallel. Certain it is that I have met with no de- 
 scription of an exactly similar instance, though the develop- 
 ment of wandering ova into cysts is a possibility recognized by 
 several authors, especially by Boinet. Dr. Lloyd Roberts, of 
 Manchester, has described a similar cystic tumor which he re- 
 moved successfully, which had no connection with the uterus or 
 ovaries, and which he regarded as a non-fecundated ovule which 
 had dropped into the peritoneal cavity, and there become enor- 
 mously developed. 
 
 I have met with quite a series of cases to which I think no 
 other explanation can be given than such as I have advanced 
 for the case described above. In none of them were there any- 
 thing like dermoid structures, though in other respects they 
 closely coincided with its appearances, and they had features 
 perfectly in common, more particularly in the matter of their 
 relations to the pelvic and abdominal organs. The series in- 
 cludes six cases, of which I need only describe one, as there was 
 nothing different in any of them, either in appearance, treat- 
 ment, or result. They were all young women, from fifteen to
 
 OVARIAlSr TUMORS, CONDITIONS WHICH SIMULATE THEM. 185 
 
 twenty-six years of age. and they had all the physical characters 
 of parovarian cysts. When I came to operate, however, I found 
 that between the cyst and the peritoneum there was an absolute 
 adhesion, and when I opened the cyst I evacuated a large quan- 
 tity of perfectly limpid fluid. The cysts were lined with epithe- 
 lium, and had a perfectly smooth, glistening surface. They 
 were intimately adherent to the whole of the pelvic surface and 
 also to the posterior abdominal wall. For some two or three 
 inches above the pelvic brim this adhesion extended in a slop- 
 ing line forward, upward, and outward to a level an inch or two 
 above the umbilicus. From this line of attachment the cysts 
 seemed to be free, and when emptied the intestines pushed down 
 the upper wall into the cyst cavity like a huge pouch. In every 
 one of the cases the uterus and ovaries could be felt, in their 
 normal situation, through the*cyst-wall, and, as far as could be 
 determined, perfectly healthy, and independent of the cyst. 
 
 They were therefore not ovarian tumors, and they certainly 
 were not of parovarian origin ; and the uniformity of their rela- 
 tions makes it, I think, certain that they form a specific class of 
 pathological cysts. In the first case I met with, which was sent 
 to me by Dr. Eshelby, of Stonehouse, some years ago, I tried very 
 liard to remove the cyst, but failing to do so, I inserted a large 
 drainage-tube, keeping it in for some weeks, and in this way I 
 cured the cyst, and the girl now remains perfectly well. 
 
 The same history is to be given of the other five cases, and in 
 the last four I have been able to recognize at once the nature of 
 the case, and have therefore made no attempt to enucleate the 
 tumor, but have been content with draining it in the method de- 
 scribed. 
 
 My impression about these cases is, as I have said, that they 
 are cysts formed by a dropsical distention of an ovule which had 
 not been impregnated and which dropped into the peritoneal 
 cavity and had there become attached and developed. 
 
 There is a class of tumors which closely simulate cystic tu- 
 mors of the ovary which I have seen occasionally referred to in 
 published accounts of operations as extra-peritoneal cysts, and 
 in one case, at least, the description is such as makes it clear that 
 the writer regards the tumor as having been a true ovarian cys- 
 toma developed outside the peritoneal cavity. It is, of course, 
 absolutely impossible to accept any such explanation for these 
 tumors, for one cannot see how a tumor of the ovary, or a tu- 
 mor developed from a wandering ovum, could by any possibility 
 be developed on the outer side of the membrane of the perito- 
 neum. In my own practice I have only seen two cases of extra- 
 peritoneal cysts, and in both of them the operation unfortu-
 
 186 DISEASES OF THE OVARIES, 
 
 nately proved fatal. As no post-mortem examination could be 
 obtained in either instance, it remains quite uncertain what the 
 exact nature of the tumor really was, though I think I have a 
 satisfactory explanation to give of them. 
 
 The first case that I met with was in a lady, aged fifty-six, 
 under the care of Dr. Lamb, of Albrighton, who for twelve 
 months before had complained of abdominal pain and tender- 
 ness, and in October, 1880, began to suffer from somewhat seri- 
 ous symptoms, more particularly frequent vomiting and disin- 
 clination to take solid food. Some swelling in the lower part of 
 the abdomen was noticed about the same time, this being then 
 regarded as ascitic. The symptoms slowly increased in severity 
 until February 11, 1881, when a consultation was held between 
 Drs. Lamb, Heslop, and Saundby. As a result of this consulta- 
 tion she was tapped and ten pints of fluid were removed, 
 though this was by no means the quantity of fluid in the cav- 
 ity, because large masses of flocculi obstructed the tube of the 
 trocar, and prevented the complete emptying of the cyst. Some 
 of this fluid was submitted to me for an opinion, and from 
 the facts that it was brown and thick and gave an abundant 
 flaky, yellow deposit which consisted chiefly of pus, I unhesita- 
 tingly gave the opinion that it was not ascitic, but a fluid that 
 must have been contained in some cyst cavity, probably a cyst 
 of the parovarium. I saw her on February 13th, when we found 
 that the abdomen was quite as much distended as before the 
 tapping. I therefore proposed an exploratory incision for the 
 removal of the tumor, if it were possible to remove it, although 
 the extremely exhausted condition of the patient gave no very 
 great prospect of success. It was perfectly clear, however, that 
 if left alone nothing but death could be the result, and therefore 
 an operation was accepted by her attendants and relatives. 
 
 I opened the abdomen at the usual site, and after cutting 
 through all the layers except the peritoneum I came upon the 
 cyst wall. I opened the cyst and removed about thirty pints of 
 fluid exactly the same as that which had been removed at the 
 tapping, and mixed up with it I found large masses of the fibri- 
 nous deposit, which accounted for the failure of the tappiug to 
 remove the whole of the fluid. I then proceeded to remove the 
 enormous cyst, which was uniformly attached to' the parietal 
 wall on its outer aspect and to the outer surface of the thickened 
 peritoneum on its posterior aspect. The cyst did not dip into the 
 pelvis at all, and the anterior parietal peritoneum did not reach 
 the wall lower than the ensiform cartilage. The intestines and 
 the pelvic organs could be felt through the anterior peritoneal 
 fold, non-adherent and, as far as could be determined, perfectly
 
 OVARIAN" TUMORS, CONDITIONS WHICH SIMULATE THEM. 187 
 
 healthy. The cyst lay, therefore, entirely between the trans- 
 versalis fascia on the outer side and the parietal peritoneum on 
 the inner, the peritoneal cavity having been nowhere opened 
 during the protracted and severe operation. The cyst was ro- 
 nioved in its entirety, and its inner surface consisted of broken- 
 down mucoid epithelium, infiltrated everywhere with pus, lying 
 upon the basement-membrane, which consisted almost entirely 
 of muscular fibre. 
 
 The conclusion concerning the nature of this cyst at which I 
 have arrived is that it was developed from the urachus, a part 
 of which had been occluded at both ends, but during the de- 
 velopmental changes of embryonic and infantile existence had 
 not become obliterated. I entirely fail to see any other possible 
 origin for it, and if my explanation be correct it is very marvel- 
 lous that this structure should have remained quiescent for fifty- 
 six years and then should suddenly undergo an inflammatory 
 change which developed it into this enormous cyst. The patient 
 went on very well for about three days and then rapidly sank 
 from exhaustion. No post-mortem examination was allowed, 
 and therefore I can shed no further light upon it, and as far as I 
 know the observation is unique, although it is perfectly well 
 known, as I myself have repeatedly had occasion to observe, that 
 small cysts of the urachus are opened in abdominal section. I 
 do not know that any such cyst has previously been met with 
 sufficiently large to be of pathological importance. 
 
 The second case of extra-peritoneal cyst was sent to me by 
 Dr. Craig, of Stoke-upon-Trent. Here again the patient was 
 almost hopelessly beyond the reach of surgical interference be- 
 fore I saw her. The tumor had been recognized by Dr. Craig in 
 1878, and then he had recommended her to put herself under my 
 care for its removal. She. however, declined to do so until the 
 middle of last May, and when she arrived in Birmingham she 
 was practically moribund. I happened to be from home when 
 she reached my house, and my servants were under the impres- 
 sion she would never leave the house alive. She was placed in 
 lodgings close by, and I operated upon her immediately on my re- 
 turn, three days afterward. The cyst I found gangrenous and 
 full of pus, with a large mass of broken-down lymph. It was 
 situated entirely outside the peritoneum, which was never 
 opened at all, and it dipped down into the pelvis on the right side 
 only. As far as I could make out, its structure was very much 
 like the other, save that it extended almost entirely on the right 
 side, the peritoneum seeming to be pushed altogether toward 
 the left. Its characters were very much like those of Dr. Lamb's 
 case just described.
 
 183 DISEASES OF THE OVARIES. 
 
 She rallied from the operation very well, and for eight days 
 seemed likely to recover, but as soon as the stitches were re- 
 moved from the womid it reopened and continued to discharge 
 a large quantity of unhealthy brown purulent fluid until her 
 death, seventeen days after the operation. Here again, unfor- 
 tunately, no post-mortem examination was obtained, and there- 
 fore I can say nothing with absolute certainty as to the origin of 
 the tumor, but my belief is that this also was a cyst of the 
 urachus. 
 
 In both of these cases I inserted drainage-tubes into the cavity 
 left by the cysts, and I am under the impression these tubes had 
 something to do with the fatal results, though this may not be 
 the case. The explanation of the deaths is of course first of all 
 to be found in the advanced condition of exhaustion in which 
 both patients were at the time of operation, and I think it very 
 likely that a fortunate result would have been obtained in both 
 of them if the operations had been performed earlier in the his- 
 tories of the cases. Perhaps the immediate cause of death was 
 the destruction of the vitality of the peritoneum, which was as- 
 sociated with the inner wall of the cyst. In both cases the ex- 
 tent of peritoneum denuded from the cyst-tissue, to which it 
 doubtless owed its blood-supply, was very great, and if this im- 
 portant structure died from loss of its blood-supply, it would of 
 course be quite sufficient to account for the deaths of the 
 patients. I think if I should ever have similar cases I should 
 feel inclined to remove a large portion of this denuded perito- 
 neum and trust to a careful arrangement by sutures of the por- 
 tions left rather than run the risk of what I think may have 
 been the cause of death, for I often find I have to remove in 
 cases of adherent cyst a very large piece of parietal peritoneum, 
 and this is done without interfering in any way with the recovery 
 of the patient. 
 
 These cases illustrate very well the unexpected and great dif- 
 ficulties which arise in the practice of abdominal surgery, and 
 how much we have yet to learn in this important branch of our 
 art. They also illustrate the abundant causes we have for re- 
 gretting that abdominal tumors are often allowed to go so long 
 as to remove any reasonable prospect of success in dealing with 
 them. 
 
 Before dealing with the very numerous conditions which sim- 
 ulate ovarian tumors it will be convenient if I now discuss the 
 signs and symptoms by which an ovarian tumor may be recog- 
 nized; and I may here say at once that the conditions which 
 mimic these tumors are so numerous, and there are so few 
 facts in connection with them upon which implicit reliance can
 
 OA^AKIAIS" TUMOllS, CONDITIONS WHICH SIMULATE THEM. 189 
 
 be placed, that safety is to be found only in the process of 
 reasoning by exclusion; that is, for a proper diagnosis in the 
 case of an ovarian tumor it will be found the best plan, first of 
 all, to make a mental list of all the conditions that it may be, 
 and exclude them one after another until no alternative is left. 
 Any one who habitually follows a converse plan will sooner or 
 later be led into some fatal blunder. Our anxiety should always 
 be, not to prove that a given tumor is ovarian, but to show that 
 it cannot by any possibility be anything else. 
 
 It may be said with perfect certainty that from the history 
 alone no ovarian tumor could be diagnosed, so various are the 
 stories told by the patients about their cases. Thus one patient 
 will present herself totally unaware of the fact tliat there is any 
 tumor, her only sensation being one of discomfort from the swell- 
 ihg, while another may have known for many years of the pres- 
 ence of a small lump which had long remained quiescent, and 
 had taken to enlarging only for a few weeks or months. The 
 rate of increase gives no guide, either in unilocular or in multi- 
 locular tumors ; for I have removed multilocular tumors which 
 had been in progress for a great many years, and I have re- 
 moved one of great size from a patient aged sixty-six, which 
 had grown in four months. I have removed, on the other hand, 
 a large unilocular parovarian tumor which had been in existence 
 for more than ten years, and the structure of which showed that 
 it always had been unilocular ; and I have removed two unilocu- 
 lar tumors, one of which grew so as to completely distend the 
 abdomen in seven weeks, and another, almost as large, which 
 had not been noticed for more than five weeks. 
 
 The details given by the patients as to the region in which 
 the tumors were first observed are often very misleading, and no 
 dependence whatever can be placed on some. One patient, in 
 whom there existed an undoubted fibroid tumor of the uterus, 
 asserted that it originally grew somewhere in the neighborhood 
 of the spleen, and gradually descended to its present uterine 
 situation. Tumors of one ovary are often stated by their bearers 
 to have originated on the side opposite to that from which they 
 are found to grow. One condition which on rare occasions comes 
 under our notice, hydatids of the peritoneum, beginning as it 
 does generally by rupture of an acephalocyst of the liver, pre- 
 sents usually a history of origin at the upper part of the abdo- 
 men ; so that, when such a story is given with subsequent gen- 
 eral enlargement of the abdomen, caution is necessary before 
 excluding hydatids from the possibilities. A tumor which began 
 centrally and remains so is of course likely to be uterine ; but 
 this is far from being constantly the rule. I have heard a pa-
 
 190 DISEASES OF THE OVAEIES. 
 
 tient state that an ovarian tumor of considerable size had ap- 
 peared suddenly ; and this might have really happened, for its 
 escape from the pelvis might have been sudden. I have often 
 pushed an ovarian tumor out of the pelvis that had been im- 
 pacted there,' and the same thing may be experienced with 
 uterine myomata. 
 
 The menstrual histories given by patients with ovarian tu- 
 mors have been so various, in my experience, as to lead me al- 
 most entirely to disregard them in the diagnosis. Dubois asserted 
 that he had not known an ovarian cystic tumor accompanied by 
 hemorrhage, but this has been repeatedly noticed in my prac- 
 tice ; and the explanation of the apparent discrepancy is that, 
 when the great obstetrician wrote, the diagnosis of pelvic tu- 
 mors had not arrived at its present state. In some instances, 
 two of which I have already detailed, ovarian tumors gave rise 
 to uncontrollable monorrhagia, and I have pointed out that there 
 seems to be a close association with small cystic ovaries and this 
 serious symptom. 
 
 I have frequently known complete arrest of menstruation to 
 be associated with rapidly growing tumors both of the ovary and 
 parovarium. Such a fact in the history of any case ought to 
 make us especially careful to eliminate pregnancy, more espe- 
 cially the condition of hydramnios, wdiich I have known to be 
 treated fatally on two occasions by tapping, once as an ovarian 
 tumor and once as ascites. The uterus, in the early months of 
 normal pregnancy, is not unfrequently displaced to one or other 
 side, and has been often mistaken for an ovarian cyst ; in one 
 case, by myself, for an abscess in the broad ligament. In this 
 latter case, I was led astray by the general symptoms of hectic 
 from which the patient suffered. It was to me a lesson to trust 
 to no one symptom, nor to any group of symptoms, in a pelvic 
 diagnosis ; fortunately the patient recovered completely after a 
 miscarriage. 
 
 A large number of cases of ovarian tumor are met with near 
 the climacteric period of life, and it is not unusual for their ap- 
 pearance to be ushered in by a premature arrest of menstruation : 
 so that during the first few months of the growth of the tumor 
 the patient takes it for granted that she is pregnant. It is some- 
 what curious that I have had at the same time under my care 
 two cases upon whom I performed ovariotomy, in both of whom 
 pregnancy was believed to exist for many months until the lapse 
 of time made an investigation advisable. Arrest of menstrua- 
 tion occurred in both before the tumor was observed, so that the 
 abdominal enlargement was of course taken for pregnancy. In 
 one case the abdominal parietes were so dropsical that it was a
 
 OVAETAN TUMORS, COIN-DITIOT^S WHICH SIMULATE THEM. 191 
 
 matter of great difficulty to be certain that there was not preg- 
 nancy as well as an ovarian tumor, the difficulty being overcome 
 by the use of the sound after some hesitation. 
 
 For the diagnosis of ovarian tumors, either subjective or dif- 
 ferential, there are varieties of symptoms, almost numberless, 
 the great majority being of little or no consequence for accu- 
 racy, and none of them alone being trustworthy. The symp- 
 toms vary in their character and intensity very much according 
 to the size of the tumor, though this is far from being the rule. 
 Thus the largest ovarian tumor which I have removed, some- 
 where over one hundred pounds in weight, gave rise to no other 
 symptoms than the inability of the patient to get about from its 
 immense weight ; while the smallest, only six and a half ounces, 
 was the source of agonizing pain and a great variety of reflex 
 symptoms, including aphonia ; and it had completely disabled 
 the patient for some years. In the early growth of a simple cyst, 
 symptoms of any kind are seldom met with until the tumor is 
 sufficiently large to be impacted in the pelvis. The growth of 
 dermoid cysts, on the contrary, is often accompanied by pain of 
 a most intense kind, for which no explanation can be advanced. 
 
 In one case, already referred to, I had to remove a very small 
 dermoid cyst on account of the agonizing pain in it. Though 
 this has been relieved completely, a variety of nervous symp- 
 toms have supervened, very mysterious in their nature, for 
 which no remedy has been found, and which, among other re- 
 sults, have induced a contraction in the hamstring muscles, and 
 an absolute rigidity of the knees, so that the patient has never 
 been able to walk since the operation, now nearly ten years. 
 
 As a rule, pain is not met with until cystic tumors are large 
 enough, if out of the pelvis, to press on important viscera; or 
 unless the surface of the tumor undergoes inflammatory change. 
 In the latter case, pain and increase of pulse and temperature are 
 the indications, though it is surprising to what an extent a tumor 
 may be found to be adherent, and yet, throughout its history, no 
 indications of inflammatory attacks have been given. Until the 
 tumor is sufficiently large to interfere with nutrition, and if it 
 be not of a cancerous character, there are rarely any symptoms 
 of constitutional disturbance; though sometimes I have seen a 
 small tumor very loose in the cavity of the abdomen give rise to 
 great pain and discomfort. Such tumors also occasionally give 
 rise to symptoms of intestinal obstruction, as was the case in the 
 instance of a large uterine myoma which I successfully removed 
 by abdominal section. 
 
 During the growth of an ovarian tumor, the appetite is usually 
 not interfered with until the case is far advanced; nor is sleep,
 
 192 DISEASES OF THE OVAniES, 
 
 though it is often found that the patient can lie only on one side; 
 nor do we find that either the temperature or the pulse is affected 
 to any appreciable extent. Hysteria is sometimes found in con- 
 nection with ovarian tumors, and dependent directly upon them. 
 In one of my cases this was markedly the fact, for the hysteria 
 disappeared entirely after recovery from ovariotomy. Hysterical 
 symptoms are in constant association with phantom tumors, and 
 these cases, in the days of the early ovariotomists, w^ere in sev- 
 eral instances operated upon by mistake. 
 
 The enlargement of the veins often seen in the skin of the 
 abdomen in cases of ovarian tumor is of no great assistance as 
 a diagnostic sign, for it is present in almost every other disease 
 simulating ovarian dropsy. Any very marked enlargement of 
 the veins may, however, be a reason for suspecting malignant 
 disease if the other indications be negative. In one or two in- 
 stances I have seen this enlargement the only indication of the 
 cancer found on opening the abdomen. 
 
 As the tumor enlarges, the symptoms become more numerous 
 and various; thus in the pelvis, by pressure on the rectum, blad- 
 der, and nerves, it may give rise to dysuria or incontinence, to 
 constipation or diarrhoea, and to various neuralgise. In the ab- 
 dominal cavity, by pressure on the stomach, liver, and dia- 
 phragm, it produces very frequently nausea and vomiting, and 
 distaste for food; in one case in my own experience it caused 
 jaundice; and very often difiSculty of breathing, amounting in 
 the latter stages to orthopnoea, is induced. Coincidently with 
 the production of these visceral symptoms, indications of great 
 systemic alterations come on gradually, due partly to direct in- 
 terference with nutrition and partly to its perversion. Thus the 
 patient becomes thinner, and the skin dry and often hot, the 
 eyes sink, and the features become pinched, and then comes on 
 the peculiar expression of face which has been named the " facies 
 ovariana." The legs at this stage generally become oedematous, 
 from the mechanical obstruction to the return of the blood from 
 the limbs, and the oedema extends to the vulva and over the 
 lower and central walls of the abdomen. When the tumor has 
 reached such extreme size as is indicated by these symptoms, if 
 then seen for the first time, its diagnosis becomes a matter of 
 some difficulty, even by the careful consideration of its signs; 
 for it is in the very small and in the very large ovarian tumors 
 that the diagnosis is most difficult. In those of medium size the 
 task is much more easy. 
 
 The physical signs which indicate the presence of an ovarian 
 tumor come under the notice of the surgeon, as a rule, only 
 when the tumor has reached a size sufficient to have obliged it
 
 OVAllIAISr TUMOES, CONDITIONS WHICH SIMULATE THEM. 193 
 
 to rise out of the pelvis, and appear as an abdominal enlarge- 
 ment. It is often, however, necessary to determine the nature 
 of a small pelvic tumor, and, as I have already said, to remove 
 it. Such a diagnosis is a matter of no great difficulty to any one 
 accustomed to make the bimanual examination, more especially 
 if it be conducted while the patient is under the influence of an 
 anaesthetic. An ovarian tumor will be found to be almost in- 
 variably behind the uterus, that viscus being pressed forward 
 close to the pubic bone; and its fundus may, save in exception- 
 ally obese patients, be felt just above the pubes. Usually the 
 uterus can be fixed between the two hands, and then no doubt 
 can be entertained as to what it is. Behind it is the tumor, and 
 if the uterus can be moved independently of it, and if the tumor 
 can also be raised out of thfe pelvis independently of the uterus, 
 no doubt need be felt that it is a tumor of the ovary or of the 
 broad ligament. An absolute determination between these two 
 is not a matter of much importance, but it may be made by the 
 practised fingers being able to determine a uniform intensity of 
 the fiuctuation wave in different diameters of the tumor, and by 
 this being also distinguished between the two forefingers in 
 bimanual examination. 
 
 As the tumor increases in size and rises out of the pelvis it 
 becomes somewhat more difficult to determine that it is not inti- 
 mately associated with the uterus. It may be necessary to in- 
 troduce the sound in order to determine this point; but this, as 
 a rule to which I think there can scarcely be an exception, ought 
 never to be done at the first examination. I have known a mis- 
 carriage, in more than one instance, brought on by neglect of 
 this rule by very competent surgeons. It not unfrequently hap- 
 pens that menstruation, or some loss resembling it, goes on for 
 the first few months of pregnancy; and to assert the diagnosis 
 between early pregnancy and an ovarian tumor just rising out 
 of the pelvis, at a first examination, is a task which only the 
 rash or the greatly experienced will undertake. If, with the 
 patient on her back, one forefinger on the os uteri and the other 
 on the fundus of the tumor, the two be found to embrace some- 
 thing which moves en masse, then it is, of course, certainly 
 uterine. But if the two fingers seem to be in relation with dif- 
 ferent structures, then the outside finger must search for the 
 fundus uteri, and after it has been found, and after it has been 
 ascertained that the uterus is not enlarged, and then only, the 
 sound may be introduced into the uterus, and its relation to the 
 tumor readily ascertained. The first matter, then, is to be cer- 
 tain that the tumor is not uterine. If it be not, and it be rounded, 
 elastic, and capable of being raised to some extent out of the pel- 
 13
 
 194 DISEASES OF THE OVARIES. 
 
 vis, then it is almost certainly ovarian. It still may be ovarian, 
 even if fixed to the pelvis, though it is rare that ovarian tumors 
 contract adhesions at such an early stage of their growth. If 
 fixed, then, it may be a hsematocele, or an abscess, or a soft tu- 
 mor growing from bone; but the diagnosis of all these may be 
 greatly assisted by the previous history and the general symp- 
 toms. 
 
 Examination by the rectum will often yield valuable addi- 
 tions to the information obtained by vaginal examination as to 
 the relations of a pelvic tumor, and it may be carried out accord- 
 ing to Simon's plan, by the introduction of the whole hand into 
 the rectum. This should only be done, however, under excep- 
 tional circumstances, when other means have failed to satisfy 
 the mind of the examiner, and surgeons having large hands 
 should not attempt it. Personally, I have never employed this 
 method, and I do not think it has met with very general accept- 
 ance. I saw Dr. Simon perform it several times at Heidelberg, 
 and he informed me that he never found any ill-effects from it. 
 I have since heard, however, of many disasters from its use in 
 this country, none of which have I seen published, and I think 
 it had better be dismissed. 
 
 When an ovarian tumor has risen out of the pelvis, and has 
 as yet met with none of the accidents to which they are liable, 
 and which lead to complications, its diagnosis is a matter of ease. 
 First of all, palpation will discover that it is a tumor by its re- 
 sistance, and firm pressure on it with the fingers of one hand, 
 and percussion on them with the fingers of the other yielding a 
 dull note, Avill exclude the possibility of the case being one of 
 phantom tumor; and, as the tumor pushes the intestines before 
 it upward and to each side, in these regions a tympanic note 
 v/ill give the indications by percussion peculiar to uterine and 
 ovarian tumors, what I have termed the "tympanic corona."' 
 It must be remembered, however, that some intestine may have 
 slipped down in front of an ovarian or uterine tumor, or some 
 may be adherent there, so as to produce a note of clear reso- 
 nance. This condition is, however, very exceptional, and if a 
 resonant note be found in front of the tumor the chances are 
 greatly against it being ovarian. 
 
 Mr. Spencer Wells has pointed out one very exceptional con- 
 dition which may completely baffle us in drawing conclusions 
 from the percussion sign. I have never seen it, am very doubt- 
 ful about it, and therefore I give at length an extract from his 
 lectures on the subject : 
 
 " Another point of doubt and difficulty may arise from the air 
 having entered an ovarian cyst; for, as an ovarian cyst contains
 
 OVARIAX TUMORS, CONDITIONS Wllicn SIMULATE THEM. 195 
 
 a certain amount of fluid, it may also contain gas, and either 
 the fluid is decomposed after tapping, or there may have been 
 some possible communication set up between the intestine and 
 the interior of the cyst. Sir Thomas Watson records a case in 
 which a patient had a cyst filled alternately with fluid and with 
 air; when the fluid collected to a certain quantity it seemed to 
 open some valve-like communication with the intestine, emptied 
 itself, and became filled with air. As the fluid gradually re- 
 formed, the air was displaced, and the same series of changes 
 went through again. I have known a case in which air dis- 
 tinctly entered." 
 
 To exclude the possibility of the tumor being uterine, some 
 care is necessary; but it is not difficult when the educated touch 
 has determined that the tumor fluctuates, and that, throughout 
 its extent, the peculiar wave passes which is found on gently 
 striking any part of a bag of fluid while the hand rests on some 
 other part of its circumference. A knowledge of what fluctuci- 
 tion is, and what this peculiar thrill is, is not easily communi- 
 cated by description, and it requires long practice to be able to 
 recognize it accurately. 
 
 If the wave be equally distributed in every direction all over 
 a tumor, then, in all probability, it is unilocular. A multilocular 
 tumor, or one composed of two or three large cysts, may often 
 be recognized by the practised fingers detecting a difference in 
 intensity of the wave along different diameters of tlie tumor. 
 There are two conditions, however, which must be carefully ex- 
 cluded from the possibilities, and, just because they are both very 
 uncommon, their probabilities are every now and then over- 
 looked. They are cystic diseases of the uterus and hydramnios. 
 In the former, the tumor will be found associated with the uterus, 
 the latter moving along with the tumor when it is moved, and 
 being dragged upward by it to an extent that ought always to 
 make us cautious, and warn us to wait and watch. 
 
 Finally, there is that great aid to diagnosis, the employment 
 of an anaesthetic, without which, in every case of doubt, no posi- 
 tive opinion should be arrived at. When the muscles are com- 
 pletely relaxed a great deal may be determined which is not pos- 
 sible otherwise, especially in the pelvis. 
 
 I need not say that in all cases of abdominal tumor vaginal 
 examination of the pelvis is of the utmost importance. As far 
 as ovarian or parovarian tumors are concerned, the most impor- 
 tant indication is ^vhen a vaginal examination gives entirely 
 negative results, that is, when there is nothing felt in the pelvis 
 save the uterus in its normal position and freely movable. Vv^e 
 may then take it for granted that the pelvic relations of the tu-
 
 196 DISEASES OF THE OVAEIES. 
 
 mor are of the most favorable kind and that the pedicle is of 
 reasonable length. If the tumor is felt in the pelvis it will gen- 
 erally be behind the uterus, but this is by no means a uniform 
 condition. The uterus may be behind the tumor, and in that case 
 the chances are that it is sessile and a good deal of trouble will 
 be experienced in dealing with the pedicle. If the cervix is found 
 to widen out and be associated with the tumor in every direction, 
 we have a clear indication that the tumor is uterine, that is, it 
 may be pregnancy or a myoma. If the uterus is drawn up very 
 much in front and the posterior lip seems to be lost upon the 
 tumor, then we may expect a tubal pregnancy. But on the 
 other hand it is not to be assumed that a tumor felt in the pelvis 
 must necessarily be either ovarian or uterine, for I have felt in 
 the pelvis tumors of the kidney, spleen, and liver; and then we 
 may also have exceptional growths, such as malignant tumors 
 of the bones of the pelvis or of the omentum, and hydatids of 
 the peritoneum, etc., etc. 
 
 Auscultation of ovarian tumors gives chiefly negative signs, 
 but these are often of value, as in the case of perfect absence of 
 intestinal gurgling over the tumor. A loud friction-sound is 
 often heard, but this is only an indication of a dryness of the 
 peritoneal surfaces where it is heard, and there is sure to be an 
 absence of adhesions at the spot. The hydatid fremitus, as de- 
 scribed by Mr. Wells, I have never been fortunate enough to 
 meet with, though I have operated on a large number of cases 
 of this disease. 
 
 Dr. Le Double, of Tours, read a memoir at the meeting of the 
 Scientific Congress at Havre on this subject, but I have not 
 gathered from it any new facts of importance. 
 
 The best way to learn to recognize fluctuation is to practise 
 upon a large bladder having a nozzle inserted into it so that its 
 tension may be varied; for it will be found that there is a con- 
 siderable difference in fluctuation according as the cyst is tightly 
 filled or not. The sensation will also vary verj^ much accord- 
 ing to the weight with which the fingers of the examiner are 
 pressed upon the cyst; and the first instruction I have always 
 to give any one who is observing abdominal fluctuation for the 
 first time is to press as lightly as possible upon the skin. Plac- 
 ing the finger-tips of one hand gently upon the surface and re- 
 taining them there immovably, the fingers of the other hand 
 must be tapped with exceeding gentleness on the skin at some 
 little distance. I lay particular stress upon the immobility of 
 the first hand because it is not unusual to see persons endeavor- 
 ing to ascertain the presence of fluid in the abdomen by a sim- 
 ultaneous to-and-fro movement of both hands, which can only
 
 OVARIAlsr TUMORS, CONDITIONS WHICH SIMULATE THEM. 197 
 
 result in wobbling the contents without conveying any real im- 
 pression to the observer's mind. 
 
 The first thing to be learned is that in the subcutaneous layer 
 of any patient not extremely emaciated there may be communi- 
 cated between the two hands a wave something like that pro- 
 duced by the presence of fluid, but having become familiar with 
 this by practising upon a healthy abdomen, especially that of a 
 stout person, this difficulty will speedily be eliminated. 
 
 A further test in cases of doubt may be applied by the method 
 first suggested by Sir James Paget of palpating first in one di- 
 ameter and then at right angles to it, and this test will be per- 
 fectly safe if the umbilicus is included in the second diameter; 
 for pseudo-fluctuation may be perceived in the first instance but 
 will be corrected in the second. As Sir James Paget has 
 pointed out, this phenomenon is due principally to the muscular 
 tissue, which gives a thrill closely resembling the fluctuation of 
 fluid across its length but not in the direction of the fibres. A 
 very convenient position for studying this fact is the calf of the 
 leg. Having made himself familiar with this superficial sub- 
 cutaneous wave the pupil will be less liable to mistake it for the 
 superficial wave of ascitic fluid, and still less liable to mistake it 
 for the deeper wave of the fluid of an ovarian or other cyst. 
 
 Ascitic fluid may be generally recognized by the fact that it 
 is associated with the uniform occurrence of a tympanic note on 
 percussion; but when there is ascitic fluid as well as fluid con- 
 tained within a cyst, we have a double wave of fluctuation ex- 
 tremely confusing but easily recognized by practised hands. 
 There is a very simple and neat way of confirming the value of 
 the sign of percussion in such a case which I have had occasion 
 to practise, and which will almost always decide between ascites 
 and ovarian dropsy in such exceptional cases. It consists in 
 mapping out the marginal area of clear percussion note by a 
 pen-and-ink line, and then ascertaining whether a clear note, 
 obtained by percussing on a finger laid gently on the skin im- 
 mediately outside that line, can be altered to a dull note by in- 
 creasing the pressure. If this alteration takes place generally 
 round the line or throughout its greater part, it may be taken for 
 certain that an ovarian or parovarian tumor is present. On the 
 other hand, if there be a clear note somewhere over the area of 
 the swelling which is not removed by firm pressure, but is rather 
 extended or intensified, still more if pressure bring out a clear 
 note where dulness existed without it, then it will be evident 
 that ascites is present, and not an ovarian cyst. The explana- 
 tion of these signs is, that pressure round the margin of an 
 ovarian tumor will bring it into more extensive relation with the
 
 198 DISEASES OF THE OVARIES. 
 
 abdominal wall by displacing the intestines, and this is most 
 easily accomplished in the epigastrium. In the converse condi- 
 tion, when a clear note is produced by pressure in ascites, the 
 abdominal wall is brought into contact with floating intestine, 
 the mesentery of which is so short, and the quantity of fluid so 
 great, as to keep the structures apart in the absence of the pres- 
 sure. We have, further, a difference between the clear percus- 
 sion notes of ascites and ovarian dropsy, in that the former 
 readily alters its position, always appearing at the part of the 
 tumor highest in relation to the patient's position. Thus, in a 
 doubtful case, if there be a corona of clearness above the sup- 
 posed tumor, extending from the hepatic to the splenic regions, 
 and any alteration of position, such as lowering the shoulders 
 and raising the pelvis, should alter the position of the area of 
 clearness to the region of the umbilicus, then the case is almost 
 certainly one of peritoneal dropsy. 
 
 More than once I have met with a case where even this sign 
 failed me, and where I have opened the abdomen to remove an 
 ovarian tumor and found only masses of peritoneal cancer. The 
 reason of such a mistake was, that the intestines were all matted 
 together by growths in the great omentum, and were .drawn up 
 into an arch under the diaphragm. The exploratory incision, 
 however, did no harm, the patients recovering from it and dying 
 some time after from the extension of the disease. Additional 
 difficulty was created in one such case by the fact that the pa- 
 tient had been twice tapped before the operation, and no doubt 
 was entertained that a cyst had been emptied, and that the 
 masses felt were smaller cysts. I have also operated on a case 
 in which no intestinal note could be obtained anywhere. The 
 patient had suffered from recurrent peritonitis, and it was evi- 
 dent that the intestines were all behind the tumor. At the op- 
 eration this was found to be the case, and the adhesions were of 
 the most formidable character. Yet the patient recovered witli- 
 out a bad symptom. 
 
 The rapidity with which the waves travel is governed by 
 three conditions chiefly. First, the thickness of the abdominal 
 walls, and this will also influence the sharpness with which the 
 wave is felt. The tension of the cyst will also materially affect 
 the wave transit, for in the tightly filled cyst the wave rushes 
 along with great rapidity, while in the flaccid cyst, it is trans- 
 mitted much more slowly and is so much less easily perceived 
 that the unpractised observer may altogether miss, it. If the 
 contents of the cyst are thick and gluey it may be altogether 
 impossible to obtain anything like a distinct wave of fluctuation, 
 and there are many cases of really solid tumors, nlore particu-
 
 OVARIAN TUMORS, CONDITIONS WHICH SIMULATE THEM. 199 
 
 larly the oedematous variety of uterine myoma, which are suf- 
 ficiently soft to give a wave of fluctuation which makes it im- 
 possible to discriminate them from ovarian cystomata with 
 gluey contents. In fact I do not know anything more difficult 
 to teach than the many facts about this sign of fluctuation. I 
 do not know anything requiring longer practice and greater 
 variety of experience for being perfectly learned ; but I also 
 know nothing giving greater diagnostic power when the fingers 
 have been sufficiently trained to perceive its differences. Thus, 
 given a case of ovarian tumor in a young woman and another 
 case of advanced pregnancy, the practised fingers alone, without 
 any question being asked, without a vaginal examination being 
 even proposed, and without the use of the stethoscope, will in 
 the majority of cases at once be able to make an exact diagnosis; 
 while in the case of a large uterine myoma, the mere sense of re- 
 sistance upon the first impact of the hand is often enough to de- 
 termine the nature of the case. This " sense of resistance" is a 
 thing quite impossible to teach. I saw it first practised by Dr. 
 Warburton Begbie, and have seen him diagnose accurately and 
 by it alone between an effusion of fluid in the pleura and con- 
 solidation of the lung. Similarly in the abdomen this sign is 
 nearly always enough to enable me to discriminate between 
 pregnancy, an ovarian tumor and a solid mass, though of course 
 I should never dream of trusting to it alone. 
 
 Of a similar character is the sign to which French writers have 
 given the term hallottement. This is not confined in its useful- 
 ness by any means to the determination of pregnancy. In a case 
 where there is an abdominal tumor surrounded by ascitic fluid, 
 the latter may be easily recognized by the sign of fluctuation, 
 but the tumor may escape observation if an effort be not made 
 to discover its hallottement. It is my uniform practice, therefore, 
 in examining an abdomen in Avhich I am satisfied of the presence 
 of ascitic fiuid, to place the fingers of one hand upon the skin 
 very lightly, and then with a steady and somewhat rapid move- 
 ment downward the ascitic fluid is made to move away, and if 
 there be a tumor the fingers come promptly in contact with it 
 and convey a sensation which cannot be mistaken. In cases of 
 doubtful pregnancy this sign is well enough known, and there, 
 of course, it is the liquor amnii which is displaced by the sudden 
 movement of the foetus which is felt. This hallottement may be 
 determined through the abdominal walls with quite as good ef- 
 fect as through the vaginal cul-de-sac. If the fluid outside the 
 cyst be small in quantity, its diagnosis is of no great conse- 
 quence ; but if large, its non-recognition may lead to serious 
 mistakes. For instance, in one of my cases I satisfied myself
 
 200 DISEASES OF THE OVARIES. 
 
 that there was an ovarian tumor from the signs given by per- 
 cussion, and that there was evidently some ascites from the 
 double wave of fluctuation. The patient was of an enormous 
 size, and the growth had not existed for more than six months. 
 It was a grave question whether I had to deal with a multilocu- 
 lar tumor having one or two very large cysts and a small quan- 
 tity of ascitic fluid, or with a small tumor and a large quantity 
 of ascitic fluid. The only method of deciding the question would 
 have been to tap the abdomen above the tumor by my blunt tro- 
 car, and to have evacuated the ascitic fluid only ; but to this the 
 patient would not accede, and I had to begin the operation in 
 serious doubt. The result showed that the plan referred to would 
 have been a wise one, for it proved to be a comparatively small 
 tumor with an enormous ascitic collection, all the intestines hav- 
 ing been pushed above the tumor. There are some minor signs 
 which often serve to indicate the presence of ascites to any 
 marked extent, such as the protrusion of fluid through the om- 
 phalic ring, carrying in front of it a layer of peritoneum like the 
 finger of a glove. The uniformity of the enlargement by ascitic 
 fluid is greater than that produced by ovarian dropsy, though in 
 the case just referred to this indication failed me ; for it was the 
 want of symmetry in the measurement which suggested that the 
 chief cause of the enlargement was cystic. The readiness of 
 alteration of the form usual to an abdomen distended by perito- 
 neal dropsy was also absent ; for, in whatever position the pa- 
 tient lay, the same outlines were preserved ; and the greatest 
 proportional increment of measurement had occurred between 
 the umbilicus and the pubes. This peculiarity is usually an in- 
 dication of ovarian cysts or of uterine tumors. 
 
 I have already uttered a warning, which I think it neces- 
 sary to repeat, concerning the use of the sound ; and here I may 
 introduce the account of a very singular experience in which 
 the use of the sound, instead of being an assistance, might have 
 led me into a very serious mistake, had I not been familiar 
 with the fact that every now and then a case occurs in which 
 the fundus uteri is perforated by the sound while it is being 
 used in an ordinary way by one quite accustomed to its use and 
 without any undue force. Such perforations never do any harm, 
 and I used to see them often when I used the sound a good deal, 
 but now that I use it hardly at all I have not seen one for a very 
 long time. 
 
 Some years ago I drew attention to cases of persistent metro- 
 peritoneal fistula in which the condition has been one of inter- 
 est only on account of its curiosity, but in the following case it 
 presented features of great importance in the diagnosis of an
 
 OVARIAN TUMORS, CONDITIONS WHICH SIMULATE THEM. 201 
 
 ovarian tumor. S. W , aged forty-nine, and unmarried, was 
 
 sent to me from a distance in September, 1874, on account of an 
 abdominal enlarg-ement which had been in progress for three 
 months, and had reached a considerable size. The parietes were 
 extremely thin, and the wave of fluctuation was everywhere ex- 
 tremely vivid. Behind the uterus was a round nodular mass, 
 freely movable, and the sound readily entered the uterus for 
 three inches. I diagnosed ovarian dropsy, and admitted her 
 into the hospital for the purpose of removing the tumor. 
 
 At a consultation, held on October 8th, some doubt was enter- 
 tained by some of my colleagues that it might be a case of peri- 
 toneal dropsy, and to assist the diagnosis the sound was intro- 
 duced by Mr. Ross Jordan. It readily passed in seven inches 
 toward the left side, though there was absolutely no force used 
 in its introduction, the instrument seeming to slip in most easily. 
 I at once expressed my opinion that the uterus had been perfo- 
 rated, and with the consent of my colleagues I proceeded with 
 the operation. The tumor was removed without difficulty, and 
 the nodular mass behind the uterus was found to be a small 
 fibroid growth in the fundus. It was the right ovary which was 
 removed, the left being quite healthy ; and as the pedicle Avas 
 very short, and the uterus somewhat dragged upon, I did not 
 think myself justified in endeavoring to gratify my curiosity by 
 looking for the point of perforation. From the position of the 
 fibroid, however, I am certain that the aperture must have been 
 situated in the anterior wall, for the fundus was completely retro- 
 flexed, both Fallopian tubes being carried with it. It is proba- 
 ble that the anterior wall had become very attenuated, or even 
 completely perforated, from being stretched over the fibroid by 
 the retroflection, this latter being evidently due mainly to the 
 pressure of the tumor from above. 
 
 Whether Mr. Jordan made the perforation or not, it made no 
 difference to the progress of the case, for she got well without a 
 bad symptom, and went home on the twentieth day. She called 
 on me eight weeks after the operation with the wound almost 
 healed. I passed the sound very cautiously into the uterus, and 
 found that it readily entered three inches, and then met with the 
 usual obstruction. I happened, however, to move its point about 
 a little, and found that toward the left side of the cavity it 
 slipped through a hole, and made itself immediately perceptible 
 under the integuments to the left of the cicatrix. The right 
 cornu of the uterus was tilted upward toward the wound, on ac- 
 count of the adhesion of the pedicle, and I know that the sound 
 could not have passed through the Fallopian tube on that side, 
 for it had been embraced by the clamp ; while the thinness of
 
 202 DISEASES OF THE OVARIES. 
 
 the abdominal walls and the fixidity of the uterus enabled me to 
 determine that the sound had clearly passed through the ante- 
 rior wall somewhere to the left of the middle line of the organ. 
 
 In addition, therefore, to the interesting fact which my for- 
 mer cases clearly established, that we may have permanent 
 communications formed between tlie peritoneal cavity and the 
 cavity of the uterus other than those of the oviducts, and with- 
 out any deleterious results, we have in this case the further fact 
 of great clinical importance, that these abnormal apertures may 
 be the cause of confusion in diagnosis. If I had not been firmly 
 convinced, from the physical signs, that my patient really suf- 
 fered from an ovarian tumor, the passage of the sound inward 
 for seven inches, in the hands of one so careful and so skilled as 
 Mr. Jordan, would have so staggered me that I should have 
 fallen into error. 
 
 Familiarity with the somewhat common occurrence of such 
 apertures, however, enabled me to have the courage of my 
 opinions. 
 
 In my earlier practice I placed considerable reliance upon 
 tapping as a means of diagnosis in abdominal tumors, but fur- 
 ther experience has led me to distrust it. Some of my reasons 
 for distrusting tapping will be given at greater length in another 
 chapter and others I have already discussed. 
 
 In cases where there is ascitic fluid its removal may indeed 
 help us to map out the position and size of a tumor with greater 
 accuracy, or the removal of the fluid from a cyst may help us 
 to determine that it is parovarian, or that it is ovarian, from 
 the fact that other cysts or solid matter were left behind; but 
 beyond this tapping helps us but little. It serves in no way to 
 clear up the nature of a doubtful tumor, nor does it reveal 
 what the intimate relations of that tumor may be. The opera- 
 tion has its own special risks, and our more recent experience 
 shows that these risks are greater than, or at least as great as, 
 those of a simple exploratory incision. I therefore prefer the 
 latter in all cases, for if we can do no more than relieve the pa- 
 tient of a quantity of ascitic fluid, or of the contents of one or 
 more major cysts, we can do this far more effectually by a small 
 exploratory incision than by the wound of a trocar, and with 
 quite as little risk. 
 
 Of the occasional misfortunes which follow tapping, I had a 
 very notable instance in the case of a patient sent to me some 
 years ago by Dr. Laidler, of Stockton-on-Tees. She was of enor- 
 mous size, so that it was advisable to tap her befoi^e removing 
 the tumor. Unfortunately, the cyst-walls were permeated by 
 large venous sinuses, and one of these was injured hy the trocar,
 
 OVARIAN TUMORS, CONDITIONS WHICH SIMULATE THEM. 203 
 
 SO that several pounds of blood poured into the cavity of the 
 emptied cyst, and the result was unfavorable to the success of 
 the subsequent ovariotomy. Besides such an exceptional risk as 
 this, there is the possibility of suppuration of the cyst after tap- 
 ping, and the infection of the peritoneum by its septic contents. 
 Finally, by means of an exploratory incision, which need not 
 as a rule be more than an inch and a half or two inches long, we 
 can ascertain absolutely the nature of the tumor and very many 
 of its relations, and we may generally obtain information con- 
 cerning it altogether beyond the reach of a tapping. This latter 
 operation, therefore, I have almost entirely excluded from my 
 practice for any purpose of diagnosis, and it is now only used for 
 relief in those cases where removal of the tumor is impossible. 
 When it is absolutely necessary to tap, the operation is best per- 
 formed by a trocar which I have devised, having a steel point 
 with a chisel edge, which is almost blunt. The patient having 
 been placed in a convenient position, a puncture is made by an 
 
 Via. 29. 
 
 ordinary lancet into the cyst, and the trocar is made to follow 
 the track of the lancet. The trocar is so simple that it never can 
 be out of order; it forms a solid rod, which is extremely useful 
 as a probe, and its point is sharp enough to penetrate an inner 
 cyst, and yet so blunt as to be incapable of mischief save in the 
 hands of the clumsy or the careless. Great care should always 
 be taken to empty completely the cyst which is tapped, and to 
 prevent the admission of air, and for this latter point the perfect 
 solidity of my trocar is the most absolute guarantee. 
 
 Tapping by the vagina was an operation a good deal in vogue 
 about eight or ten years ago, and I have had two cases in which 
 cysts of some kind were permanently cured by this means; but 
 as it is by no means always attended with good results, I have 
 almost discontinued it. I have known death occur three times 
 after it, and I may state as my general conclusion that I have a 
 growing distrust of tapping of any kind, either by the aspirator 
 or the trocar, and in all cases where treatment is or may be an 
 object, as well as diagnosis, I infinitely prefer an abdominal 
 section. 
 
 The diagnosis of the variety of tumor in each case is of im-
 
 204 DISEASES OF THE OVARIES. 
 
 portance in guiding us to its treatment; therefore it is not for 
 the mere exercise of ingenuity that I recommend every practi- 
 tioner dealing with a case of ovarian tumor to exhaust every 
 point on which I have dwelt, together with many others to which 
 I have not alluded, but which the individual peculiarities of each 
 case and his own personal shrewdness may suggest. Above all, 
 let me again urge the necessity of reasoning by exclusion, and of 
 making repeated examinations at intervals before any certainty 
 of diagnosis is felt. Three times it has occurred to me to remove 
 ovarian tumors which had hastily been set down at an early 
 period of their history as floating kidneys, that diagnosis hav- 
 ing been made in all three cases because the wish was father to 
 the thought, and because the practitioners who made it had not 
 learned the value of patience. It is this want of patience that is 
 to blame for those melancholy instances of blunders, altogether 
 unpardonable, where the abdomen has been opened in cases of 
 normal pregnancy mistaken for ovarian tumors. 
 
 There are many conditions which simulate ovarian tumors 
 besides those already alluded to, and I propose now to devote 
 some space to the consideration of as many of these as have oc- 
 curred to me in practice. I have no doubt there are others which 
 may yet arise in my experience, but I think the list I am about 
 to give is a fairly inclusive one. 
 
 In the earlier experiences of abdominal surgery many cases 
 occurred in which an operation was performed for the removal 
 of an ovarian tumor and no tumor found ; that is to say, where 
 there was no condition whatever to justify the mistake. During 
 the last twenty or twenty-five years, however, I have not heard 
 of any instances of this kind, indeed the introduction of ansesthet- 
 ics has rendered such a misfortune all but impossible. We can 
 easily understand how such mistakes as those so candidly nar- 
 rated by Mr. Lizars could occur. We can only admire the frank- 
 ness with which he published them, and acknowledge the great 
 service the publication rendered to his successors. It is a trite 
 saying, but one worthy of frequent repetition, that we learn a 
 great deal more from our blunders than we do from our suc- 
 cesses. 
 
 Before the introduction of anaesthetics the most likely condi- 
 tion to give rise to such a mistake was that singular disease known 
 as phantom tumor or phantom pregnancy, to which the name of 
 pseudocyesis has been given by Goode. This singular disease is 
 certainly an affection of the nervous system, and lies in that 
 border-land which exists between hysteria and insanity, and 
 where everything in the Avay of explanation consists merely of 
 guesswork. There can be no doubt that whatever may be the
 
 ovariajS" tumors, conditions which simulate them. 205 
 
 mechanism of this disease, its immediate exciting cause is inti- 
 mately associated with the ovaries, as indeed is the whole group 
 of hysterical diseases. We know, however, that these affections 
 are by no means unknown in the male sex, and I have seen a 
 marked case of phantom tumor in a male, and singularly enough 
 a medical man was the victim of the fancy. Mr. Spencer Wells 
 {British Medical Journal, June, 1878) says he saw a phantom tu- 
 mor in a soldier who came down from the Crimea to Smyrna 
 with an abdominal enlargement which entirely disappeared 
 when the man was narcotized with chloroform. Perhaps this 
 was a case of malingering. 
 
 Simpson, quoting Harvey and giving also his own experi- 
 ence, tells us that symptoms such as we find in these cases are 
 to be observed in cows and bitches ; and doubtless, if accurate 
 observations were to be made on these animals so affected, some 
 kind of explanation would be arrived at. That the symptoms 
 are due to a perverted intelligence, or a mere desire to defraud, 
 is not an explanation which would apply to many cases which 
 have come under my own observation, and it could scarcely be 
 urged in the case of animals. I have failed, however, to find that 
 in cows or bitches any of the imitative symptoms have often been 
 observed; that is to say, such symptoms as distention of the abdo- 
 men seldom occur. The signs of the spurious pregnancy in them 
 consist in the reflex phenomena which accompany true preg- 
 nancy, and this points conclusively to some false start given to 
 the reflex mechanism which connects the ovaries and uterus 
 with their subsidiary organs and the system generally. 
 
 Dr. S. Haughton, F.K.S., made a communication to the Dub- 
 lin Obstetrical Society on February 7, 1880, on a case of phantom 
 tumor in an ass. Having purchased a fine specimen of a rare 
 variety of zebra, he was anxious to provide a suitable partner 
 for him ; he therefore obtained a healthy three-year-old virgin 
 ass. It was necessary to have a virgin, as it was known that 
 the first intercourse gave a stamp to the subsequent progeny. 
 Frequent and apparently satisfactory intercourse took place be- 
 tween the two. The ass came into season at intervals of five 
 weeks, and remained so from ten to fourteen days, and its period 
 of utero-gestation was eleven months. It was therefore easy to 
 discern when the animal was in foal. After six weeks, the ass 
 began to enlarge visibly, and a man much accustomed to the 
 breeding of horses declared that he could "feel the foal inside 
 her." The eleven months expired, and the ass came into season 
 again without having given birth to a foal. After a lapse of four 
 months she was again given the zebra, and again she swelled, 
 continued so for eleven months, and again gave birth to noth-
 
 206 DISEASES OF THE OVARIES. 
 
 ing. In this case he considered that the mental element might 
 be disregarded, for the ass could have no object in deceiving, and 
 her illusion of being in foal influenced her physiological condi- 
 tion, for her mammary glands were enlarged, and w^hen the 
 supposed pregnancy was over they subsided with the abdominal 
 enlargement. 
 
 The great majority of cases of phantom tumor are really in- 
 stances of spurious pregnancy incompletely developed; indeed, I 
 am not quite sure but that every case really is so; those about 
 which I have doubt being of a class which are certainly hysteri- 
 cal, which have no other sign than abdominal distention, and 
 which seem to me perfectly analogous to crib-biting among 
 horses. I have seen a suflicient number of these to be able gen- 
 erally to distinguish them as they enter the consulting-room, by 
 the one sign which can always be heard, loud intestinal gur- 
 glings. These gurglings are due to the swallowing of air which 
 the patient indulges in for a few minutes before she visits the 
 surgeon, and she generally begins the consultation by attracting 
 attention to them and to her large size. The increase in size is 
 partly due to the spurious flatulence and partly to the peculiar 
 muscular rigidities which these patients indulge in. If the pa- 
 tient is kept engaged in conversation for fifteen or twenty min- 
 utes, without an opportunity of renewing her air supply, the 
 gurglings will entirely cease and she will markedly diminish in 
 size. Physical examination, especially under an anaesthetic, at 
 once confirms the spurious nature of the abdominal distention. 
 In these cases there is usually no attempt on the part of the pa- 
 tient to induce the surgeon to believe that she is pregnant, or 
 even that she has a tumor, and the belief that a deliberate and 
 voluntary fraud is intended is, I think, to be justified only in ex- 
 ceptional cases. The object seems really to be that of gratifying 
 that insatiable love of attracting attention so deeply rooted in the 
 female mind, a weakness which is at the bottom of ninety-nine 
 cases of hysteria out of every hundred; and it must be borne in 
 mind that this desire is characteristic of many forms of insanity 
 in men as well as in women. The majority of cases of eccentric 
 hysteria occur in women to whom nature has denied the exter- 
 nal attractions of beauty, or in whom there is not the compensa- 
 tion of a refined and cultured intellect. It is therefore in neg- 
 lected and ill-educated women that these objectionable forms of 
 hysteria are chiefly to be met with. I have seen the kind I am 
 now speaking of imitated by crib-biting mares and geldings very 
 closely, the best instance having occurred in a rhare. She was 
 generally required to go out at a particular time of day, and as 
 that hour approached, if she could succeed in getting a hold of
 
 OVARIAi^ TUMORS, CONDITIONS WHICH SIMULATE TIIEM. 207 
 
 any fixed object with her teeth she would secure a quiet day in 
 the stable by rendering herself quite unfit for w ork for many 
 hours. She would swallow large gulps of air, so that the disten- 
 sion looked, to those unaccustomed to it, almost like the last 
 stage of a peritoneal dropsy, and the intestinal gurglings could 
 be heard at many yards distant. In a few hours she would be 
 ■well again and ready for work; but nothing could prevent her 
 succeeding in her trick unless care was taken to have nothing 
 about upon which she could fix her teeth. 
 
 Women who indulge in this objectionable habit are nearly 
 always sterile, though I can call to mind two cases in mothers 
 of large families. It is by no means confined to any period of 
 life, as I have seen it in very young and in very old women. 
 
 Between this group and those in which there is always pres- 
 ent a distinct conviction that they have a tumor, there is no de- 
 fined line, but they are generally women of the same type. 
 They do not usually, however, have the gurglings, the disten- 
 sion being produced entirely by some peculiar muscular fixation, 
 in which probably the diaphragm is the chief factor. In order 
 to distend the walls of the abdomen, the first step is to fix the 
 diaphragm at as low a level as possible; and after this is done, 
 breathing can be carried on by the ribs alone. The time through 
 which this kind of respiration can be employed is very brief in 
 men, but is practically unlimited in women, owing to the pecu- 
 liar superior costal method of breathing which exists in them. 
 After fixing her muscles in this way, a woman has only to throw 
 her shoulders back and her pelvis forward, and if her clothes 
 are loose she at once presents the appearance of pregnancy; and 
 in these cases, if the confidence of the patient be sufficiently 
 reached, it will always be found that there is either a hidden de- 
 sire or a concealed dread of pregnancy. Generally, there is 
 some little sign, or a group of symptoms, which gives coloring 
 to the suspicion; such as morning sickness, pain in the breasts, 
 flow of milk, or arrest of the menses; but in those cases where 
 there is no expressed belief in the existence of pregnancy, the 
 history of the symptoms given seldom leads up to that supposi- 
 tion, and the patients are generally very reticent in giving their 
 own impression. Between this second group of cases and the 
 third, in which I class those in which the belief in pregnancy is 
 expressed, and both its symptoms and signs given with more or 
 less completeness and without hesitation, there is no well-defined 
 distinction; for cases present themselves in which the condition is 
 not sufficiently complete to place them under the heading of spuri- 
 ous pregnancy, and yet where there is evidently a belief on the 
 part of the patient that there is something more than a swelling.
 
 208 DISEASES OF THE OVARIES, 
 
 A ■well-marked case of spurious pregnancy, with its train of 
 imaginary symptoms well described, and its reflex phenomena 
 well developed, is one of the most singular experiences any one 
 can have, and is most bewildering to those unaccustomed to 
 physical examination of the pelvis. It is by no means confined 
 to women at the climacteric, as many authors seem to have taken 
 for granted without having properly analyzed the facts ; and it 
 is not even confined to married women, or such as have engaged 
 in sexual functions without being married ; for I have seen a 
 very well-marked case in a young woman, twenty-two years of 
 age, who presented all the usual and most trustworthy features 
 of virginity. 
 
 There is some peculiar nervous machinery put in action the 
 moment a fertilized ovum becomes attached to the uterine or 
 tubal mucous surface, and that machinery sometimes gets a false 
 start. How this occurs, we do not know, but the result is the 
 appearance of all the symptoms without the reality of pregnancy. 
 
 One of the most perfect cases of phantom pregnancy or pseu- 
 docyesis which I have ever met with, was one I saw in consul- 
 tation with Dr. Charles Warden and Mr. Machin, of Erdington. 
 The patient was thirty-two years of age, had been married eleven 
 years, and had menstruated with perfect regularity until June, 
 1872. Menstruation was then suddenly and entirely arrested, 
 she slowly increased in size, and had morning sickness and 
 many other symptoms of pregnancy. The breasts enlarged, she 
 described the sensations of quickening, and she engaged Mr. 
 Machin to attend her in the confinement she expected in March. 
 Nothing, however, came of it. When I saw her in the follow- 
 ing May she presented all the appearances of being pregnant at 
 the full time, the breasts containing quite an abundant supply 
 of milk, and the question to be considered was, had she an extra- 
 uterine pregnancy? As the uterus was perfectly normal, hav- 
 ing no tumor of any kind in association with it, this suspicion 
 was at once dispelled ; and on placing her completely under the 
 influence of ether it became at once apparent that the preg- 
 nancy was a phantom, which ultimate test for pseudocyesis is 
 one of the many triumphs of gynaecology due to the genius of 
 Simpson. This patient was in the same condition in 1879. 
 
 Another condition which frequently gives rise to the suspi- 
 cion that the patient is suffering from a tumor, and therefore, of 
 course, most probably an ovarian tumor, is the curiously rapid 
 growth of omental fat which many women put on at the climac- 
 teric period. Only a few days ago a remarkable instance of this 
 occurred in my experience, the description of which will serve 
 for all I have to say upon this subject.
 
 OVAHIAIS" TUMORS, CONDITIONS WHICH SIMULATE TIIEM. 209 
 
 A lady was brought to nie from a distance by her medical 
 attendant, who was a gentleman of exceptional experience 
 and ability, but, of course, like other men engaged in general 
 practice in the country, he had but very occasional opportunities 
 for obtaining experience in the diagnosis of abdominal tumors; 
 and, as he frankly told me, he knew very little about them. He 
 brought his patient to me because he was in doubt, and there 
 was no discredit due to him by reason of his difficulty. The pa- 
 tient was forty-seven years of age, and for about a year her men- 
 struation had become irregular, her abdomen had increased very 
 much in size, and she had lost flesh in the face and limbs. Her 
 arms bore distinct evidence of this, for the subcutaneous fat had 
 disappeared from them and the skin was wrinkled and flabby. 
 Her abdomen was large, and, as she said, dresses she could wear 
 only a few months before, she was now wholly unable to put on. 
 As she lay on the couch the appearance was certainly that of an 
 abdominal tumor, but the moment I touched the abdomen and 
 felt the tight condition of the skin, I suspected what I had to 
 deal with. The layer of subcutaneous fat there was extremely 
 thick, for on taking up a handful of the skin it was found to in- 
 clude considerably more than two inches of fat. All over the 
 abdomen a clear resonant note could be determined, no traces of 
 fluctuation could be detected, the cavity of the pelvis was per- 
 fectly normal, her functions were healthy, and nothing distressed 
 her but the size of her abdomen. But for my previous experi- 
 ence in such cases I might have hesitated to give the opinion I 
 did, that the case was nothing but a climacteric accumulation of 
 fat in the abdomen. I comforted both the patient and her doc- 
 tor with the assurance that after the climacteric period was over 
 a redistribution of fat would probably occur, that it would be- 
 come more equalized over the body and less pronounced in the 
 abdomen, and this I have seen occur so many times that I have 
 little doubt that in the case I am describing I shall find in about 
 two years that my prognosis will be verified. 
 
 This of course was a somewhat extreme case, because it is 
 much more usual to find a general increase in the adipose tissue 
 of the body than that it should be deposited in the abdomen at 
 the expense of the other regions. I can, however, recall to mind 
 a sufficient number of mistakes which I have made in such cases 
 as this to be able to give a warning to others to be cautious in 
 expressing an opinion concerning the existence of a tumor 
 merely from an increase in the size of the abdomen of a woman 
 at the climacteric period. 
 
 Another of the conditions which simulate ovarian tumors, 
 and one about which we must be more cautious than any other, 
 14
 
 210 DISEASES OF THE OVARIES. 
 
 is pregnancy. I have already said that during the whole period 
 of gestation menstruation may occur with normal regularity 
 and in normal quantity, and also that a rapidly growing ovarian 
 cystoma may arrest the menstrual flow. It has been my experi- 
 ence, as it must have been the experience of every special prac- 
 titioner, to have patients brought to me as suffering from tumor 
 when their real state was that of pregnancy, and I need hardly 
 say that this occurs chiefly in unmarried women. I have, how- 
 ever, had it occur more than once in a married woman, and I 
 can call to mind an instance of this of a somewhat dramatic 
 kind. 
 
 A lady forty-two years of age who had been married twice 
 and whose married life extended over eighteen years was 
 brought to me by her doctor as a case of ovarian tumor. With 
 very great difficulty indeed I persuaded him that it was a case 
 of pregnancy, and that she must be within a few days of her 
 confinement. My opinion, however, was entirely disbelieved by 
 the patient, and it was only when the pains of labor came upon 
 her that she accepted the accuracy of my opinion. She was 
 confined of a dead child and her labor very nearly cost her her 
 life. Only a few days ago a hospital patient was sent to me as 
 being a case of ovarian tumor. She was of very large size, the 
 feet and legs were much swollen, nothing could be felt in the 
 pelvis, and she had seen no appearance of menstruation for six- 
 teen months. Yet a careful stethoscopic examination revealed 
 the sounds of the fetal heart, and by getting my hand into the 
 vagina I found the cervix normal, though very high up. It 
 turned out to be a case of pregnancy with cardiac dropsy. 
 
 In the event of a young unmarried woman presenting herself 
 with an abdominal tumor the utmost caution must be observed, 
 for there is no limit to the persistency of the denial such patients 
 will make as to their condition. Medical experience is full of 
 illustrations of this, and I have heard very many anecdotes from 
 my professional brethren illustrating it. Some of their patients 
 even went so far as to deny the possibility of their being preg- 
 nant when labor was in the third stage. A few weeks ago a 
 patient came to the hospital to consult me concerning an ab- 
 dominal tumor. It was manifestly a case of advanced preg- 
 nancy. Yet when it was delicately suggested what the possi- 
 bility of her state was, she indignantly denied it; but when I 
 proceeded with the requisite examination I found not only that 
 she was pregnant but that the recto-vaginal septum had been 
 completely destroyed in a previous labor. No amount of scep- 
 ticism in these cases will therefore be too great, but the prac- 
 titioner will be wise who keeps that scepticism to himself. If
 
 OVARIAN TUMOES, CONDITIONS WlllCn SIMULATE TIIEM. 211 
 
 the tumor is of small size and the patient is not suffering, only 
 two questions need be asked — is her menstruation arrested, 
 and, if so, was it regular previous to its recent stoppage ? If 
 these two questions are answered in the affirmative, I would 
 advise that an examination should not be made at the first visit 
 but that some slight placebo be given and the patient be asked 
 to repeat the visit at an interval of seven or eight weeks; and at 
 the same time some gentle hint may be dropped that the case is 
 probably one of a nature that will not require operation. In the 
 majority of cases I find this is quite enough, and that the patients 
 very soon realize their position and do not trouble me again. If, 
 however, they should come back, upon the second or third visit I 
 advise that an investigation should be made. I need not here 
 describe the evidences upon which we base a diagnosis of preg- 
 nancy, and shall allude to one only in detail, because it is one 
 but little known as yet, and it is a sign more valuable perhaps 
 even than that derived from auscultation, in that it can always 
 be observed, whereas the fetal heart cannot always be heard. I 
 mean the rhythmical contraction of the uterus. If the hands bo 
 placed on the abdomen of a case of suspected pregnancy and a 
 fluctuating tumor be felt, that tumor will become quite tense 
 and like a myoma if the examination be prolonged for a few 
 minutes. Then again it will become flaccid and fluctuating, and 
 this alternation will go on rhythmically at varying intervals. 
 Once this sign has been felt and* recognized, I think it will be 
 impossible for the observer ever again to be deceived by a preg- 
 nant uterus. Let me again impress upon every one the neces- 
 sity of caution in giving an opinion to the effect that a patient 
 is pregnant. 
 
 A most disastrous case of this kind occurred some years ago 
 in my practice, where a young and very attractive girl, who suf- 
 fered from an ovarian tumor which I subsequently removed, 
 was examined by four different practitioners, all of whom were 
 men of experience and two of whom saw the patient together in 
 consultation. All four of these men asserted, I am told, that 
 they heard the fetal heart, a sign which is regarded as conclu- 
 sive of the existence of pregnancy. The girl when seen by me 
 communicated none of these facts; she was brought to me by 
 her parents and I knew nothing of her previous history. I had 
 no hesitation at all in pronouncing it to be a case of ovarian 
 tumor, and in the course of a few days I removed it. One of the 
 practitioners under whose care she had been, was foolish enough 
 to continue his statement that the girl had been pregnant and 
 that my statement that I had removed an ovarian tumor was a 
 falsehood. For this extraordinary conduct he was very properly
 
 212 DISEASES OF THE OVARIES. 
 
 called to account by the parents of the patient, and it was only 
 by his tendering a most ample apology that he was saved from 
 an action for damages. Fortunately for me it happened that 
 the operation was performed in the presence of two gentlemen 
 who knew both the patient and the practitioner, so that it was a 
 very simple matter for me to prove the accuracy of my state- 
 ment. 
 
 The interest of the case centres upon this: How was it that all 
 these four men declared that they heard the fetal heart ? I am 
 bound to say that upon this point I can offer no possible expla- 
 nation, unless it be that some curious intestinal sound of a rhyth- 
 mical character was given out during their examinations. But 
 the case is such a striking one, and has, I believe, been so disastrous 
 to the practitioner to whom I have alluded, that I quote it as a 
 warning to every one to exercise the utmost caution in pronounc- 
 ing an unmarried woman pregnant. Nevertheless, when such a 
 patient presents herself, the suspicion of pregnancy must be ever 
 present in the mind, for it is by far the most likely condition, and 
 it must only be by repeated examination and the concurrent tes- 
 timony of physical signs that any positive opinion should be 
 given. Far better at any rate to defer an opinion for some time 
 than to run into sucli a mistake as that I have instanced. 
 
 One other caution I shall give in connection with such cases, 
 and that is never under any circumstances employ a sound 
 where there is a possibility of ipregnancy. 
 
 Sometimes pregnancy may coexist with an ovarian or par- 
 ovarian tumor, and this might of course happen in an unmarried 
 woman, though I have never seen such a case. But it is by no 
 means infrequent in married women, and then the diagnosis is 
 a matter of very great difficulty. We are, however, removed 
 from the risk somewhat by the fact that married women are 
 much more likely to assume they are pregnant than that they 
 are not, and attention will be drawn to their condition more by 
 unusual size than by any other feature, and they have no in- 
 ducement to conceal the possibility of pregnancy. 
 
 Here I may mention one of the abnormal conditions of preg- 
 nancy which every now and then leads to a terrible disaster by 
 being mistaken for a peritoneal dropsy or an ovarian tumor. In 
 this disease, hydramnios, we have of course an arrest of men- 
 struation for some months, generally four or five, and this ought 
 to lead to a suspicion of what is the matter; but on the other 
 hand, being one of the diseases of the primiparous woman, we 
 liave it unfortunately more frequently, or at least quite as fre- 
 quently, in unmarried women as in married women. It is always 
 associated with albuminuria, and very often in its course we have
 
 OVARIAN TUMORS, CONDITIONS WHICH SIMULATE THEM. 213 
 
 the characteristic convulsions of that disease when it is asso- 
 ciated with pregnancy. I have seen eight cases of hydramnios, 
 and I am very pleased to be able to say that I have not been led 
 into the blunder of tapping any of them. Seven out of these 
 eight cases have been associated with twin pregnancies, and this 
 is too great a proportion to be a matter of accident. They have 
 all occurred in primiparous women, and the most advanced case 
 had reached only the sixth month of pregnancy. The disten- 
 tion of the uterus in all of them had taken place with amazing 
 rapidity; in one case the limit of time was probably less than a 
 fortnight. I would therefore advise that any young woman 
 whose abdomen was found to be large, and in whom the distention 
 had occurred with great rapidity, the first thing to be examined 
 should be the urine, and if this be found to be albuminous, let 
 every proceeding be taken with the utmost caution. Of course 
 no intestinal note of resonance will be found save at the usual 
 seat of the corona, and on pelvic examination the distention of 
 the uterus will be made clear. This is easily determined by get- 
 ting the patient into the erect position and then making a vaginal 
 examination. The child or children will then be found settling 
 down on the point of the finger, and can easily be felt through 
 the thinned uterus. A slight push will send the mass floating 
 up toward the fundus, whence it will sink in a few seconds. In 
 this way I have readily made a differential diagnosis between a 
 unilocular ovarian cyst and a distended uterus. 
 
 The diagnosis will then be complete, and the treatment, which 
 is to empty the uterus as rapidly as possible, to administer 
 chloroform freely in the event of convulsions, and to give such 
 remedies as are appropriate for puerperal albuminuria, may at 
 once be proceeded with. 
 
 I have known three practitioners, all men of ability and ex- 
 tended experience, who have been unfortunate enough to tap a 
 patient suffering from this disease, and who were immensely 
 surprised to find the patients miscarry in a few hours and die 
 shortly afterward. When conversing with these men I found 
 that none of them had ever heard of this unusual disease; and 
 yet^ from my own experience. I can hardly regard it as extreme- 
 ly rare. It is, however, but slightly alluded to in the text-books 
 upon these diseases. 
 
 There is another disease in which fluid is collected in the cav- 
 ity of the uterus, owing to occlusion of the cervix, and to which 
 the name of hydrometra has been given. This condition is prob- 
 ably very rare: I have only seen one case. It is rather difficult 
 to understand how it is arrived at, more particularly in such a 
 case as that which came under my care, in which the patient
 
 214 DISEASES OF THE OVARIES. 
 
 was nineteen years of age and had menstruated for about three 
 years in the normal way. Before I saw her, menstruation had 
 ceased for about two years, and her abdomen had steadily in- 
 creased in size. The physical signs were all those of a parova- 
 rian cyst, and I did not examine the condition of the pelvis be- 
 cause the patient was a virgin. I proceeded to operate in the 
 ordinary way, and found there was no appearance of the layers 
 of peritoneum. After passing through what was clearly a thin 
 layer of muscular tissue, I opened the sac and removed nine 
 pints of clear limpid fluid. The inside of the cyst was rugose, 
 and the cyst itself rapidly contracted after being emptied. 
 Passing the forefinger of my right hand into the vagina and 
 having my left forefinger in the pelvis, I made out clearly from 
 the relations of the cervix that the cyst was truly the cavity of 
 the uterus. I fastened in a drainage-tube, and kept it there for 
 about three weeks, and after its removal the wound speedily 
 healed. The patient has since remained in perfect health, but 
 has never menstruated. I doubt very much if I should have 
 diagnosed the case any more completely if I had examined the 
 pelvis previous to the operation, and the mistake I made fortu- 
 nately turned out to be of no importance. Had I been able to 
 make a correct diagnosis of the case it would have been an easy 
 matter to have passed a drainage-tube through the cervix with- 
 out performing abdominal section. This disease is only alluded 
 to by authors as a possibility, and there are very few descrip- 
 tions of cases, such as there are being described as having oc- 
 curred in old women after the climacteric. There is one excep- 
 tion, given by M. Richard aS a case of hydrosalpinx in which, 
 when he applied pressure, he was able to force the fluid into the 
 uterus and out of it. His diagnosis may of course be correct, 
 but I think that it much more likely was a case of hydrometra. 
 
 The retention of menstrual fluid within the cavity of the 
 uterus from occlusion of the cervix, or more frequently from 
 atresia of the vagina, is a much more common occurrence. I 
 have seen some seven or eight cases of it, but in none of them 
 did there seem to be much possibility of it being mistaken for an 
 ovarian tumor. In the first place the patient is nearly always 
 brought under notice on account of the intense menstrual pain 
 due to the monthly additions to the contents of the uterus. The 
 history was given in all of them that no external appearance of 
 menstruation had occurred, and these two circumstances alone 
 are suflScient to suggest the true nature of the case. Examina- 
 tion of the patient will reveal two things which are decisive. 
 The first is the presence of a tumor of comparatively small size, 
 smooth, ovoid, central in position, and very tender to the touch;
 
 OVARIAN TUMOES, CONDITIONS WHICH SIMULATE THEM. 215 
 
 and, secondly, there will be found some form of malformation of 
 the genital canal. If there be doubt, an examination under ether 
 will easily reveal the fact that the tumor is uterine. Some cases 
 of this kind are described as occurring in women who have men- 
 struated normally and who have even borne children, the occlu- 
 sion having been due to the union of the uterine lips or of the 
 walls of the vaginal canal after some injury or ulceration. I 
 have not seen such a case, but the symptoms would be the same, 
 and the history would probably give a significant clue to the 
 diagnosis. 
 
 There are two remaining conditions of the uterus which may 
 require to be differentiated from ovarian tumors, one of which 
 is much more common than the diseases I have just spoken of. 
 They are fibro-cystic tumors and myomata. The fibro-cystic 
 tumor of the uterus is an extremely rare affection, so rare that 
 until four months ago I had never seen a case, and in that case 
 it was absolutely impossible to distinguish the growth from a 
 parovarian cyst. She was sent to me by Dr. Leacrof t, of Feck- 
 enham, and was seen by me originally about five years ago, when 
 I diagnosed a parovarian cyst and advised its removal. This she 
 declined, and in the interval she was tapped several times by Dr. 
 Leacroft, at each tapping the tumor being apparently emptied 
 and no solid matter being left. She had never been pregnant, 
 was fifty -three years of age at the time of the operation, and 
 had menstruated all her life with perfect regularity, until the 
 age of fifty. After the climacteric period the tumor grew with 
 great rapidity, and it was after the change that she was first 
 tapped. When examined the uterus appeared to be quite free 
 from the tumor, and the physical signs were those of a unilocular 
 and therefore probably parovarian cyst. At the operation I found 
 the tumor to be densely adherent all over its front aspect, and I 
 had not been engaged in its separation long before I recognized 
 the familiar appearance of uterine tissue. It was quite impossi- 
 ble to remove the whole of the tumor, which consisted entirely 
 of one cyst, and I left about one-sixth of it in the pelvis, cutting 
 it off as low down as I could by means of the cautery and tying 
 several large vessels. Subsequent examination gave conclusive 
 evidence that the walls of the tumor were composed of uterine 
 tissue. The operation was an extremely severe one, for numerous 
 coils of intestine had to be separated from the posterior wall of 
 the tumor and both ureters were laid bare. She had no bad symp- 
 toms for four days, but upon the fifth she began to sink and died 
 upon the seventh. A post-mortem examination was made by Dr. 
 Saundby. who found that the space occupying the lower third of 
 the abdomen contained a considerable quantity of bloody fluid,
 
 216 DISEASES OF THE OVARIES. 
 
 on removing which a suppurating area was discovered. The 
 lower part of this consisted of tiie remains of the uterine mass. 
 Dr. Saundby notes that a loop of intestine had its mesentery en- 
 tirely torn away, but was living and uninjured. The left ureter 
 was compressed by old inflammatory adhesions, and the left 
 kidney was atrophied and cystic. Death in this case might, I 
 think, possibly have been avoided if I had adopted Dr. Keith's 
 plan of drainage. It is very likely indeed that a fatal issue would 
 have occurred even if the drainage-tube had been used, but if I 
 had another such case I should certainly use it. Had I operated 
 when I first saw the patient, before she was tapped, I think it 
 more than likely she would have recovered; and I also think it 
 might have been better to have clamped the cyst outside than to 
 have dealt with it by the intraperitoneal method. It is in such 
 exceptional cases that the clamp may be of service. 
 
 The growths which have usually been described as fibro-cystic 
 tumors of the uterus have been multi-cystic, and what their ori- 
 gin is I really cannot say. There seems to be no tissue in the 
 uterus from which one would expect cysts to grow, yet there is 
 no doubt they are produced in the organ. Their diagnosis as 
 ovarian tumors would be very much the same as the diagnosis 
 of myomata, with the addition that the discovery of fluctuation 
 would lead to the suspicion of cystic disease. I am under the 
 belief, however, that without experience a differential diagnosis 
 of fibro-cystic tumors would be a very difficult thing, and that it 
 is possible only in the hands of a surgeon who had made two or 
 three previous mistakes. In such a case as I have described of 
 a unilocular cystic tumor of the uterus a correct diagnosis was 
 absolutely impossible. 
 
 Concerning uterine myoma I shall only speak so far as this 
 disease simulates ovarian dropsy, for with the many other 
 phases of it I am not at present concerned, though when speak- 
 ing of ovariotomy I intend dealing more fully with it. There is 
 one most constant clinical feature characterizing myoma which 
 is seldom met with in ovarian cystoma, which alone will often 
 decide the nature of the case: I refer to menorrha^gia. I have 
 already said that there are conditions of the ovary which pro- 
 duce intractable uterine hemorrhage, but this is quite excep- 
 tional. On the other hand we see many cases of uterine myoma 
 in which hemorrhage never appears as a leading feature; still, 
 given an abdominal or pelvic tumor, constantly recurring mon- 
 orrhagia and a distinctly anaemic appearance of tlie patient, 
 the surgeon may take it for granted that the chances are im- 
 mensely in favor of the disease being a uterine myoma. On ex- 
 amining the abdomen of a patient suffering from the disease a
 
 OVARIAN TUMORS, CONDITIOISTS WHICH SIMULATE TIIEM. 217 
 
 variety of conditions may be discovered. Thus there may be a 
 large ovoid smooth tumor occupying a perfectly central position 
 and which may give rise to a feeling so closely resembling fluc- 
 tuation as to deceive the most experienced hands. 
 
 Such a case as this I operated upon three years ago, where a 
 very distinguished surgeon had previously performed dry tap- 
 ping, that is to say, he plunged a trocar deeply into the tumor 
 and got nothing out, the result of this experiment being that the 
 tumor grew with increased rapidity. When I first saw her I 
 also was under the impression that the tumor was ovarian be- 
 cause there was nothing in the pelvis to contraindicate that 
 view, and the tumor was uniformly smooth and ovoid. It was 
 only after repeated examinations that I began to entertain a 
 suspicion that the tumor was really uterine and was probably 
 one of the variety to which I have given the name of " oedema- 
 tons myoma." I advised the removal of the tumor, and when I 
 came to operate I found that this suspicion was correct. The 
 tumor grew from the fundus and was encapsulated by a thick 
 layer of uterine tissue. The body of the uterus formed an ex- 
 cellent pedicle around which I placed a clamp. The patient re- 
 covered perfectly well and is still alive, enjoys excellent health 
 and continues her occupation of monthly nursing. The tumor 
 on removal weighed thirty-seven pounds, and consisted entirely 
 of uterine muscle-cells distended into a meshwork by a large 
 quantity of serum v^^hich drained away, leaving a solid mass 
 of only about twenty pounds. The sexual functions of this 
 patient are wholly unaltered. 
 
 It is very much more common to find these myomatous tu- 
 mors perfectly solid, so that they give no sensation of fluctuation 
 at all, and instead of being smooth and uniform in contour they 
 are far more often nodulated into eccentric forms. Sometimes 
 their position is not at all central. I have seen a large myoma 
 shaped like a cocked hat running up altogether on the right side 
 and having no position at all to the left of the middle line. In 
 such a case there can hardly be room for doubt in the diagnosis, 
 for we never see ovarian tumors having such characters, at 
 least none such has ever presented itself in my experience, 
 although sometimes small outlying cysts of an ovarian tumor 
 may somewhat resemble through the skin the nodules of a 
 uterine myoma. But it is when a pelvic examination is made 
 that little room is left for doubt. Nearly always the tumor may 
 be at once determined as having a most intimate relation with 
 the uterus; and if the forefinger of one hand be kept firmly 
 pressed upon the cervix, while with the other hand the tumor is 
 made to move freely from above, the case will be easily and
 
 218 DISEASES OF THE OVARIES. 
 
 clearly determined, though here again sometimes an ovarian 
 tumor, solid and with a very short pedicle, may very closely re- 
 semble in its pelvic conditions those of a uterine myoma. Fi- 
 nally, the sound may be employed to assist in the diagnosis. In 
 an ovarian tumor the uterus is rarely elongated, vs^hile in a my- 
 oma it nearly always is; but, as I have elsewhere said, with in- 
 creased experience the surgeon will find the sound to be an in- 
 strument becoming less and less useful to him, and he will find 
 the cautions I have already given regarding its employment be- 
 coming more and more deserving of respect. 
 
 Solid uterine tumors, besides the absence of fluctuation, often 
 have in addition two vascular signs which I have never met 
 with in ovarian tumors; namely, an aortic impulse, which may 
 be seen and felt, and an enlargement of the uterine arteries to 
 be felt in the vagina. In one case I satisfied myself that the 
 tumor was uterine, mainly because at the flexure of the vagina 
 on one side I felt an artery as large as the radial. There is also 
 a uterine souffle to be heard in most of the growths, and it is 
 best heard in the vagina. 
 
 If the tumor be found to be solid but not uterine, yet attached 
 to the uterus and moving it to an extent which may lead to the 
 belief that it is ovarian, then we have a choice between a der- 
 moid cyst, a fibroid tumor of the ovary, cancer of the ovary, or 
 a pedunculated myoma of the uterus. A dermoid cyst is rarely 
 so constituted that it will not give fluctuation at some part or 
 other; and its peculiar nodulated character, with here and there 
 spots of bony hardness, will often betray it. Fibroid tumors of 
 the ovary are very rare, and cancer of the ovary alone occurs in 
 only one form, the fibroid, which is of extreme rarity. 
 
 Mere dropsical eff^usion into the cavity of the peritoneum does 
 not usually offer any difficulty in its recognition, but every now 
 and then a case will be met with in which, from exceptional 
 causes, some difficulty will occur in recognizing such a case. 
 Thus I have more than once opened an abdomen under the com- 
 plete belief that I should find an ovarian tumor, but have in- 
 stead found only masses of cancer with an abundant ascitic ef- 
 fusion. This is due to the fact that in such a case the intestines 
 have become adherent or have been wedged backward by a 
 large mass of fungus in the omentum, so that no resonant 
 note could be obtained in front, whilst it was readily given in 
 the flanks. In such a case, of course, the mistake is of no great 
 importance, for all that happens is that the patient is tapped 
 by an exploratory incision instead of by a trocar, and there is 
 the advantage that an absolute certainty of the diagnosis is 
 arrived at.
 
 OVAEIATf TUMORS, CONDITIONS WHICH SIMULATE THEM. 219 
 
 One very curious case came under my notice about two years 
 ago in a girl aged eighteen, who had an enormous ascitic effu- 
 sion. "When she was admitted under my care at the Women's 
 Hospital there was no difficulty at all in recognizing the condi- 
 tion, so that I tapped her for it more than once and was abso- 
 lutely certain that my diagnosis was correct. The girl appeared 
 to be in all respects save that of the dropsy perfectly healthy, 
 and no kind of lesion which could account for the dropsy could 
 be discovered. In order to clear up the case I transferred her to 
 the care of a friend who was a physician attached to another in- 
 stitution. There she was kept under observation for several 
 months without any additional information being obtained, save 
 that there appeared to be a small amount of effusion in both 
 pleurse; still no distinct clue could be obtained of the cause of 
 her singular condition. By a mischance she fell into the hands 
 of another practitioner, who unwisely expressed the opinion that 
 it was undoubtedly a case of ovarian disease, and he proceeded 
 to treat it on that belief. When the abdomen was opened, how- 
 ever, my diagnosis was completely confirmed, but unfortunately 
 the operator did not take advantage of the opportunity to dis- 
 cover the cause of the dropsy, so she left the institution in which 
 the operation was performed without any additional light being 
 thrown upon the case. She was tapped repeatedly until she 
 died, and then again an opportunity was lost of obtaining infor- 
 mation upon one of the most remarkable cases which has ever 
 been under my care. 
 
 Quite recently I had another singular experience of dropsy of 
 the peritoneum imitating, still more closely, cystic disease. I 
 was called by Mr. Whitcombe, the superintendent of the Bir- 
 mingham Lunatic Asylum, to see a girl in whom the abdomen 
 had increased with amazing rapidity. I diagnosed a paro- 
 varian cyst, and in a few days I opened the abdomen to remove 
 it. I found, however, that it was not a cyst of the broad liga- 
 ment, but a dropsical distention of the lesser cavity of the peri- 
 toneum, due to occlusion of the communicating cavity by peri- 
 tonitis. The inflammation was general, and in spite of drainage 
 she died of the disease in a few days. At the post-mortem it 
 was found that the whole mischief was due to a common seam- 
 stress' sewing needle lying in the great omentum just over the 
 foramen of Winslow. The patient had probably swallowed it, 
 and from the stomach it had passed out into the position where 
 it was found. 
 
 Such an occurrence is of course of the most unusual kind, but 
 of great interest as showing how difficult exact diagnosis is in 
 abdominal diseases. The case is also of value as an illustration
 
 220 DISEASES OF TUE OVARIES. 
 
 Q)i the advantage of an exploratory incision over tapping. If I 
 had tapped in this case at the usual point, I should have gone 
 straight through the large intestine which lay immediately in 
 the way, displaced by the distention of the lesser cavity of the 
 peritoneum. Death must have resulted from such a mistake. 
 My third and fourth cases of operations for peritoneal hydatids 
 are of sufficient importance to be given in full detail. 
 
 In this country hydatid disease of the peritoneum is not very 
 common, and what we know of it is chiefly derived from the ex- 
 perience of practitioners in hot countries, more particularly in 
 Australia, where this form of parasitic disease seems to be pecu- 
 liarly rife. I have seen four cases, and in but one of them 
 was I able to make a diagnosis previous to operative proceed- 
 ings. They all presented the ordinary appearance of abdom- 
 inal tumors of a cystic character, and they certainly did not 
 yield the special sign upon which so much reliance is placed by 
 some authors — the so-called hydatid fremitus. I understand, 
 however, that our great English authority upon this disease, Sir 
 William Jenner, has only noticed this sign once in his large ex- 
 perience. The invasion of the peritoneum by these parasites 
 nearly always occurs by the rupture of a sac in the liver, from 
 which the foreign organisms are set free to attach themselves 
 and begin another phase of growth in the peritoneum. 
 
 The first case which I saw occurred in the practice of Mr. 
 Langley Brown, in the person of a lady who had resided in Aus- 
 tralia and who had apparently acquired the disease there. She 
 had several distinct and separate tumors in her abdomen, and the 
 pelvis was occupied by a fluctuating tumor which we believed to 
 be a mass of hydatids. A complete record of the case is given by 
 Mr. Brown in the Birmingham Medical Review for July, 1876, 
 to which I am indebted for the following resume. There was a 
 fluctuating tumor in the recto-uterine cul-de-sac, which we be- 
 lieved to be a mass of hydatids, because in the abdomen was an- 
 other fluctuating mass attached apparently to the omentum. I 
 tapped the pelvis and drew off the contents of the mass felt 
 there, and from this operation a sharp attack of peritonitis fol- 
 lowed, which seemed to result in the death of a number of other 
 colonies, some of which at least found their way in some mj^s- 
 terious fashion through the walls of the bladder and were ex- 
 truded by the urethra. A large jarful of cysts w^re so passed, 
 much more than the bladder could have contained, and there 
 was no kidney tumor to account for them; nor is there reason 
 to believe they grew in the bladder. The explanation may be 
 that they were really extra-peritoneal, or that the pelvic mass 
 may have been a ureter. The scolices found in them were pro-
 
 OVARIAN TUMOES, CONDITIONS WHICH SIMULATE THEM. 221 
 
 nounced by Dr. Cobbold to be those of echinococcus hominis, and 
 the patient made a perfect recovery. 
 
 The second case occurred in the person of a hospital patient 
 who had spent all her life in the neighborhood of Birmingham, 
 and who had nothing in her history or in her physical signs to 
 lead me to believe the disease from which she suffered was other 
 than a cystic tumor of the ovary. Even after I had opened the 
 abdomen I found the organs so matted together with cysts of 
 varying size, having all the appearances of ovarian cysts so in- 
 timately associated with all the structures, that it was some 
 time before I recognized what the extraordinary condition really 
 was, I removed a few of the cysts, and a microscopical exami- 
 nation completely revealed the nature of the case. The tenta- 
 tive operation had a fatal result, and upon post-mortem exami- 
 nation the hydatids were found to occupy the whole abdominal 
 cavity — to have insinuated themselves into the muscles of the 
 walls and into various organs besides the liver, so that the 
 operation could not have been completed by any possibility. 
 
 R. P., aged eighteen, was seen by me in consultation with 
 Dr. Hickinbotham and Mr. Pugh, of Ashted, on December 23, 
 1881, on account of a pelvic tumor, Avith wdiich were associated 
 very severe symptoms. There was a high temperature, and the 
 pulse was extremely rapid. The patient was constantly sick 
 and presented all the appearance of being extremely ill. In fact 
 Mr. Pugh had called in Dr. Hickinbotham under the impression 
 that she was dying, and they asked me to see her on account of 
 a large mass in the pelvis, which they regarded as an abscess. 
 When I saw the patient I concurred in their view, and the pa- 
 tient was sent at once to the Hospital for Women for the pur- 
 pose of an abdominal section. This I performed next morning, 
 in the presence of Dr. Hickinbotham, Dr. Savage, and Mr. Pugh, 
 and assisted by Mr. J. Raffles Harmar. On opening the perito- 
 neal cavity I found that all the structures were matted together, 
 and that it was extremely difficult to identify any of them. The 
 adhesions were those of recent peritonitis and also the peculiar 
 agglutination caused by the presence of hydatids in the perito- 
 neum. Deep down in the pelvis, and attached to the back of the 
 right broad ligament, I found a bunch of hydatid cysts, some of 
 which I removed and others of which I ruptured. On the left 
 side was a much larger mass, which I could not touch on account 
 of the dense adhesion of layers of intestines, I therefore inserted 
 a glass drainage-tube and closed the wound over it. The tube 
 was removed on the fourth day, but the pulse and temperature 
 did not fall perceptibly till the eighth day. The sickness, how- 
 ever, ceased almost immediately after the operation, and the
 
 222 DISEASES OF THE OVAEIES. 
 
 patient complained of no pain after the third day. On the four- 
 teenth day the mass on the left side had diminished to less than 
 one-half of the size which it had at the time of the operation. 
 She left the hospital on the twenty-fourth day, at which time 
 the pelvic mass had almost disappeared, and the patient's symp- 
 toms were all gone. She had gained immensely in health and 
 strength, and Mr. Pugh reports that she is now quite well and 
 going about. 
 
 There are two points of note in this case, in that it illustrates 
 that remarkable fact, of which I have published many illustra- 
 tions, that a judiciously performed, yet incomplete, operation 
 may often effect a complete cure, and that the chief difficulty in 
 abdominal surgery is to know when to stop. The latter lesson 
 is to be learned only in the school of painful experience. 
 
 The fourth case occurred in a woman aged twenty-six, placed 
 under my care by Dr. Blackwood, of Wednesbury, in whom a 
 pelvic tumor had been growing for two years. Until last Christ- 
 mas she had suffered very little inconvenience from it, but at 
 that time it became very painful, increased greatly in size, and 
 obliged her to remain in bed. 
 
 I saw her on January 16, 1882, with Dr. Blackwood, and found 
 a large fluctuating tumor rising almost as high as the umbilicus, 
 quite fixed and extremely tender. The patient had a high tem- 
 perature and rapid pulse, and was quite unable to straighten 
 herself in bed. I was of opinion that she was suffering from a 
 large abscess, though I could not make out much in the pelvis. 
 I admitted her to the hospital for the purpose of performing ab- 
 dominal section, and this I did on January 23d. 
 
 I found the tumor to be a large sac full of hydatids. I emptied 
 it and fastened in a large glass drainage-tube, and the patient is 
 already nearly quite recovered. The cyst is quite small, and the 
 secretion from it is perfectly healthy pus. All her symptoms 
 liave disappeared. 
 
 I do not know what the relations of the cyst were, more than 
 it was in the peritoneum and had intestines adherent to it. In 
 this case, as in the other, tapping would have been quite use- 
 less. 
 
 At the present time (July 15, 1882) these cases remain per- 
 fectly well. 
 
 An equally rare condition, which it is perfectly impossible to 
 diagnose previous to operation, is one of which I have been 
 able to find only one case recorded besides the case which has 
 occurred in my own experience. In the American Journal of 
 Medical Science for October, 1852, Dr. Buckner relates a case 
 which he diagnosed as an ovarian tumor, and npon which he
 
 OVARIAIS" TUMORS, CONDITIONS WHICH SIMULATE THEM. 223 
 
 decided to operate under that belief. When he came to operate, 
 however, the tumor was found to be not ovarian at all, but a 
 cyst situated in the mesentery between the layers of the peri- 
 toneum and surrounded by small intestines. He proceeded with 
 the operation and dissected the tumor out, dividing in his pro- 
 ceeding the superior and middle mesenteric arteries, which he 
 had to tie. The patient recovered, and, in spite of the great sep- 
 aration of the mesentery from the intestine, no apparent bad 
 consequences of any kind ensued. 
 
 My own case occurred in February, 1878, and was of a pre- 
 cisely similar nature. My diagnosis before the operation was 
 that of a parovarian cyst, and if I had tapped her instead of 
 opening the abdomen I should in all probability have killed her, 
 for just at the point of election for tapping I found, as soon as I 
 had opened the peritoneum, a loop of intestine running at right 
 angles to my incision. I did not do as Dr. Buckner did — dissect 
 out the cyst; I contented myself with the much less severe oper- 
 ation of tapping it and fastening in a drainage-tube. In this way 
 I completely cured my patient and she remains to this day per- 
 fectly well. 
 
 At first sight it would hardly be thought likely that tumors 
 of the liver, gall-bladder, kidney, and spleen would often be mis- 
 taken for ovarian tumors, but I have had a large number of 
 cases of these conditions sent to me as ovarian tumors, and I 
 have on several occasions opened the abdomen under the im- 
 pression that I was about to remove an ovarian tumor and found 
 the case to be one of tumor of the kidney. On the other hand I 
 have several times removed ovarian tumors which in the earlier 
 stage of their existence have been diagnosed as floating kidneys. 
 In fact there is one physician of my acquaintance who seems to 
 have a wonderful power of finding cases of this abnormality, and 
 I think that no less than three of my ovariotomies have been 
 diagnosed by him as cases of floating kidney before they came 
 under my care. I cannot do better perhaps than quote what is 
 said concerning this by Mr. Spencer Wells in his lectures to the 
 College of Surgeons : 
 
 *' I do not think there is a specimen here, I doubt whether 
 there is in the Museum, of what is called 'movable kidney.' I 
 believe there have been only one or two such specimens shown 
 after death at the Pathological Society, but I have occasionally 
 seen tumors in the abdomen which appeared, as far as one could 
 tell, to be instances of movable kidneys, either enlarged or of 
 their natural size. One case is such a remarkable one that I will 
 detain you a moment to tell you about it. A lady came to me 
 believing she had, or having been told she had, a movable right
 
 224 DISEASES OF THE OVARIES. 
 
 kidney. I saw her with Dr. Wilson Fox, and we both agreed 
 that was the nature of the disease. For some years it went on, 
 and I saw her occasional!}^ under the impression that she was 
 suffering from a movable kidney. Then she became pregnant, 
 and pregnancy went on to its natural termination and a healthy 
 child was born. Soon afterward she began to suffer from an 
 ovarian cyst on the left side, the movable kidney still being on 
 the right side; and the ovarian cyst increased so much that it 
 was decided I should perform ovariotomy, which I did. I said 
 at the time, ' I will see what that movable kidney is now; ' and 
 after I had removed the ovarian cyst on the left side I felt what 
 the supposed kidney was and took it out, and then I found it 
 was the right ovary, but it was attached by a pedicle fully a foot 
 long. It had been held up under the right false ribs by the 
 merest little film of adhesion. Quite a small patch of adhesion 
 kept this right ovary, which was about the size of my fist and 
 very much the shape of a kidney, just in the position of a mov- 
 able kidney. The patient recovered and remained in good 
 health." 
 
 Tumors of the kidney sometimes extend so low down that 
 they can be felt in the pelvis, and they are often so movable, 
 especially from side to side, that it is quite impossible to say 
 whether they are or are not ovarian tumors. One such case was 
 placed under my care by my colleague, Dr. Hickinbotham, and I 
 opened the abdomen perfectly believing that I was about to deal 
 with an ovarian cyst. I found, however, that it was a large cyst 
 of the kidney which I could not remove, but I dealt with it by 
 opening it, emptying it, and stitching the wound in its Avail to the 
 wound in the wall of the abdomen and fastening in a wide glass 
 drainage-tube. The cyst suppurated freely. The patient was 
 completely cured in about two months. 
 
 Now that abdominal surgery has made the great advances re- 
 corded in the last three or four years, I have little doubt that tu- 
 miors of the kidney will by and by be dealt with as successfully 
 as uterine tumors certainly, and perhaps even as successfully as 
 ovarian tumors. The deliberate removal of the kidney by Simon, 
 of Heidelberg, which was successful, and the removal of a large 
 cystic kidney by Dr. Campbell, of Dundee, in mistake for an ova- 
 rian tumor, with an equally fortunate result, will probably in 
 time lead the way to further triumphs. As far as my own ex- 
 perience goes I have only once removed an enlarged kidney, and 
 in that case the success was complete, and I am glad to say that 
 all my patients have recovered from the incomplete operations. 
 
 Enlargements of the spleen have been mistaken for ovarian 
 tumors, but this is hardly so pardonable a mistake. The posi-
 
 OVARIAN TUMORS, CONDITIONS WHICH SIMULATE THEM. 225 
 
 tion of the spleen when enlarged, the history of its growth, and 
 the appearance of the patient in most cases are sufficient, I 
 think, to prevent the mistake being made. Besides this there is 
 one perfectly decisive sign in the case of a spleen which ought 
 always be looked for and will always be found. It is that on the 
 right side of the tumor may be felt a sharp edge under which 
 the fingers may be passed, especially if the patient is asleep, and 
 the tumor may then be tilted over on its own axis upward and 
 toward the left. This edge, moreover, has a peculiar arrange- 
 ment of festoons along its margin, the notches of which are 
 from three to five inches apart, and when these notches are dis- 
 covered there can be no doubt whatever of the tumor being the 
 spleen; and finally, if there should still be doubt a microscopical 
 examination of the blood will usually give abundant proof of 
 diseased spleen by the excess of white blood corpuscles. I have 
 opened the abdomen three times in the hope of being able to re- 
 move a splenic tumor, but have never yet been able to accom- 
 plish it. These three patients recovered from the operation and 
 two of them have since been completely cured. Whether that 
 was a result of the exploratory incision or not I cannot say, but 
 the patients were subjected to no other treatment for months 
 after the operation than they had experienced for some months 
 before it. The third case is yet more remarkable and is still under 
 observation, I opened the abdomen and failed to remove the 
 spleen. Three weeks afterward a large abscess formed in the 
 spleen; this I laid open, without any Listerian precautions, and 
 inserted a drainage-tube. The amount of pus in this huge ab- 
 scess was two and a half pints. The patient is slowly recovering 
 and the spleen is shrinking. I know of two cases of removal of 
 the spleen in this neighborhood both of which proved fatal; in 
 one of them the organ was removed in mistake for an ovarian 
 tumor. 
 
 Perhaps the least likely of all the conditions to which I have 
 alluded as being mistaken for an ovarian tumor would be a tu- 
 mor of the liver, yet I have to confess that in one instance I 
 committed this curious error. The patient was sent to me from 
 Leicester with all the signs of a large cystic tumor of the ovary, 
 but when I opened the abdomen I found a large collection of 
 ascitic fluid, due to a huge mass of soft cancer which grew by a 
 narrow pedicle from the liver. The abdomen was closed and the 
 patient was enabled to return home, where she died shortly after- 
 ward. I believe it would be quite possible in some extreme cases 
 to mistake a hydatid tumor of the liver for an ovarian tumor. A 
 year ago I operated upon a lady in whom the diagnosis of hyda- 
 tids of the liver was made by Sir William Jenner, and I think one 
 15
 
 226 DISEASES OF THE OVARIES. 
 
 less experienced than that distinguished physician might have 
 taken tlie tumor for an ovarian cyst. It occupied the whole of 
 the abdomen and distended it enormously, and the edge of the 
 tumor could be felt in the pelvis. I opened the abdomen and 
 then opened the liver, emptied between two and three gallons of 
 hydatids, fastened the two wounds together by continuous suture, 
 secured a drainage-tube well into the cavity, and succeeded in 
 curing the patient. The case is published in the volume of the 
 *' Transactions of the Royal Medical and Chirurgical Society " for 
 1880, and since that time I have operated upon eight other cases 
 of a similar character with perfect success in all. I have also 
 opened the distended gall-bladder and removed gall-stones in 
 three cases by a similar operation, and have in these cases also 
 had perfectly successful results, so that we have a prospect of a 
 remarkable extension of abdominal surgery in unexj)ected direc- 
 tions. 
 
 There is one condition of the ovary concerning which a very 
 great deal of discussion has taken place, and upon which I am 
 yet by no means clear that a satisfactory conclusion has been 
 arrived at. I refer to the displacement which has been described 
 as ovarian pregnancy. It is a question which has a much greater 
 interest from a pathological than from a clinical point of view, 
 because even if there be such a condition as ovarian pregnancy 
 I do not see that the treatment required for it would be in any 
 way different from that required in Fallopian pregnancy, which 
 I have fully described in another chapter. Until the appearance 
 of Velpeau's article in the " Dictionnaire de Medecine," most of 
 the cases of extra-uterine pregnancy seem to have been regarded 
 as instances of the actual impregnation and development of the 
 ovum within the structure of the ovary itself, and it is very evi- 
 dent from the description of a number of cases of dermoid tumor 
 of the ovary that these singular structures were also regarded 
 as having this origin. In fact, I think I may say that between 
 the incomplete development of a foetus in the dermoid cyst to its 
 complete development in the extra-uterine pregnancy, there 
 does not seem to have been any clear distinction until about 1850. 
 The assertion, therefore, that ovarian pregnancy does really 
 occur is made by the great majority of authors Avithout any 
 really critical examination of the facts of the case. 
 
 I have spent a great deal of time in the investigation of the 
 literature of the subject, and I am bound to say that I am scep- 
 tical as to the reality of the descriptions of any of the instances 
 which have yet been given of this phenomenon. " Spiegelberg, 
 according to Schmiet, has established the authenticity of nine 
 cases and has added ten more ; but Dr. Parry cojitents himself
 
 OVARIAiSr TUMORS, CONDITIOlsrS WHICH SIMULATE THEM. 227 
 
 with merely saying that the weight of authority is in favor of 
 the possibihty of ovarian pregnancy. Further than this I cer- 
 tainly am not inclined to go, for if we consider for a moment 
 the chain of circumstances which alone could lead to such an inci- 
 dent, we can readily understand, in the first place, how extreme- 
 ly rare its occurrence must be ; and, in the second place, how diffi- 
 cult it is to prove what is absolutely necessary — that the ovum 
 was developed within the follicle which it had never left. We 
 must imagine, in the first place, that the spermatozoa had pene- 
 trated the whole length of the Fallopian tube, a circumstance 
 which must be of extreme rarity if the views of the physiology 
 of the oviduct which I have advanced be correct. We must 
 then further see that this incident must have occurred at the 
 time when the pavilion has embraced the ovary, and the em- 
 brace must have occurred at the spot where the follicle was 
 about to rupture. After all this the most extraordinary inci- 
 dents of the process must occur : the ovum, instead of leaving 
 the follicle when the rupture takes place, must remain within 
 it ; the spermatozoa must enter through the rupture ; the rupture 
 must then heal ; the ovum must become reattached to the epithe- 
 lial lining of the follicle ; the rupture heals, and then the develop- 
 ment of the ovum must take place within the walls of its origi- 
 nal home. Supposing the whole train of these extraordinary 
 circumstances to have occurred, it would not be impossible to 
 imagine that the follicle would distend as it does in the case of 
 cystic growth, and that we should have a case of true ovarian 
 pregnancy. 
 
 During the progress and development, and in many of the 
 troublesome accidents through which all cases of extra-uterine 
 pregnancy must pass, there would inevitably occur such adhe- 
 sions and displacements as would make it most difficult to prove 
 that the actual seat of the foetus was within the tissue of the 
 ovary. Among many other conditions which would have to bo 
 fulfilled the following are some of the most important. In the 
 first place, of course it would be quite impossible to admit any 
 case as one of ovarian pregnancy in which a most careful post- 
 mortem examination had not been made, by a thoroughly com- 
 petent observer. Then we should have to find that the uterus 
 and both tubes were absolutely intact ; that one ovary was pres- 
 ent and that the other could not be accounted for save by its 
 existence as the cyst of the pregnancy ; and in the cyst wall of 
 such a case there would have to be found microscopic evidence 
 of ovarian tissue. In several cases of tubal pregnancy which I 
 have dissected it was a matter of the utmost difficulty to find 
 the corresponding ovary, even when it was perfectly clear that
 
 228 DISEASES OF THE OVARIES. 
 
 the seat of the pregnancy was one of the Fallopian tubes. In 
 one of my dissections I could not find the ovary, and yet that 
 case was, with perfect certainty, one of tubal pregnancy. In 
 Spiegelberg's paper there is only one case cited to which these 
 tests apply with any degree of satisfaction, and therefore I give 
 its details in full. 
 
 An abdominal section was performed under circumstances of 
 great difficulty, and after peritonitis had been some time in ex- 
 istence the sac had become closely adherent to the great intes- 
 tine and to the right wall of the pelvis. On both sides the tubes 
 were normally distributed, but the left one, after a course of 
 7 ctm., disappeared in the walls of its broad ligament. The right 
 tube extended 10 ctm. along the upper edge of the thickened, 
 broad ligament toward a sac which was united by the ligamen- 
 turn ova?'ii to the ala vespertilionis of the uterus; it had a di- 
 ameter of 10 ctm. and was in a collapsed condition. After the 
 tube had reached the sac it could be traced along its surface for 
 a distance of 22 ctm. and was permeable for a distance of 12 
 ctm., and in the remaining 10 ctm. of its length it disappeared 
 as a narrow, smooth band on the outer surface of the sac. There 
 v/as in this neighborhood a small dermoid cyst in the wall of the 
 sac without any distinct boundary. The sac itself had two 
 layers, the outer of which was thick and firm, and the inner 
 one fine and delicate, these two being capable of easy separa- 
 tion. The inner layer was clearly the chorion, for over its 
 greatest part it had the structure of placenta, which was thick- 
 est at the bottom of the sac and thin at the upper part. 
 
 Spiegelberg therefore concludes that the right ovary was the 
 bag containing the child. He could find no ovary on the right 
 side, but he found distinct ovarian elements in the outer wall of 
 the sac. It must here be pointed out that, in the first place, the 
 post-mortem examination is admitted to have been not very effi- 
 ciently performed, and the description given of the tube makes 
 it, I think, quite as likely that it was a case of pregnancy in the 
 broad ligament which resulted in the rupture of the tube on its 
 lower aspect — that being the most common variety of the tubal 
 pregnancies which are not fatal in their early rupture — as that it 
 was a case of ovarian pregnancy. The fact that there was pres- 
 ent an ovarian tumor is proved by the existence of a dermoid 
 cyst. This would account for the somewhat wide distribution 
 of ovarian elements in the wall of the sac, and as Spiegelberg 
 does not claim to have found ovarian elements all over the vv^all 
 of the sac, I think we may be quite justified in being somewhat 
 sceptical even about this case; though I frankly admit that the 
 eminence of the observer and the manifest care with which all
 
 OVARIAN TUMORS, CONDITIONS WniCH SIMULATE THEM. 229 
 
 his records are given make it quite possible that his conclusions 
 are correct. Since this was written, I regret to say, Prof. Spie- 
 gelberg has passed over to the majority. 
 
 In a paper published by M. Puech upon this subject he de- 
 scribes a case in which the left Fallopian tube, like the right, 
 was fixed behind the ovary by adhesion, but had remained per- 
 meable. Its pavilion was closed in great measure, but not com- 
 pletely, and admitted a probe. The left ovary measured 4G mms. 
 long, 26 mms. broad, and 18 mms. thick. It contained Graafian 
 follicles of various degrees of development, the largest being 8 
 mms. in diameter. On its outer extremity was a rounded body 
 about the size of a large cherry, its largest diameter being 20 
 mms., while its smallest was 12 mms. Its envelope was trans- 
 parent and furnished with well-marked reticulated vessels. At 
 one spot a deep violet coloration was seen over a space about 
 the size of a lentil, and around this the envelope was thickened. 
 Over most of the rest of the surface a yellowish substance could 
 be seen through the translucent envelope. On opening the cyst 
 with scissors a prominence with a villous surface was found 
 attached at the area of coloration, while over the rest of the sur- 
 face a layer ^ mm. thick could be easily separated from the cyst 
 wall. The villous prominence was furnished with large vessels, 
 and formed a semi-ellipsoid measuring 11 mms. by 10 mms. On 
 incising this with cataract scissors it was found to contain a 
 cavity distended by a clear fluid, and in the fluid floated an em- 
 bryo in the form of a vermiform body 1 m. long, curved in the 
 middle and swollen at one extremity. It was enveloped in an 
 excessively delicate membrane by which it was fixed to the pre- 
 sumed chorion. 
 
 Now of course the whole conclusion in this case depends 
 upon the assumption that this vermiform body, only 1 m. long, 
 was an embryo. It may have been one, but certainly there is 
 no proof advanced in favor of this view; and although I am by 
 no means prepared to deny its accuracy, I am certainly very 
 doubtful about it. If it was an embryo it could only have been 
 one of a few hours' existence, and one could hardly expect to find 
 the machinery of the whole process so defective that the pavi- 
 lion of the tube — the most important part of the whole machinery 
 ^•was so damaged as to be, according to M. Puech's description, 
 almost closed and fixed behind the ovary by adhesion. One 
 would have at least expected this adhesion to have been over the 
 seat of the rupture, and yet it is distinctly stated not to have been 
 so. I have seen so many queer looking things in ovarian cysts 
 and follicles that I am not inclined to admit that this vermiform 
 body has been shown conclusively to have been an embryo.
 
 230 DISEASES OF THE OVAEIES. 
 
 In another case, recorded by Walter in the Monatschrift fiir 
 Geburtshulfe (vol. xviii. ), there is a description of a cyst which 
 had ruptured and allowed the foetus to pass into the abdomen. 
 The cyst is stated to have been an ovary, but the conditions of 
 the description are not sufficiently exact for this to be admitted, 
 though it is stated that the cyst was free from adhesions to sur- 
 rounding parts and was free from the pavilion of the corre- 
 sponding tube. On the whole, I am inclined to regard the evi- 
 dence advanced so far concerning the alleged occurrence of 
 gestation within the proper tissue of the ovary as by no means 
 complete; and while I am not prepared ca.tegorically to deny 
 its occasional occurrence, as I did in a previous edition of this 
 book, 5'et I cannot admit that it has been proved. Even if it 
 does occur it would, as I have said, possess little more clinical 
 importance than a case of tubal pregnancy, a differential diag- 
 nosis of it could not be made, and it would have to be treated 
 on the same principles as the other varieties of extra-uterine 
 pregnancy. 
 
 An extremely interesting contribution to the comparative 
 pathology of the ovary has been made by Mr. Henry H. Slater, 
 in the Journal of Anatomy and Physiology (vol. xiii.), concerning 
 an ovarian tumor found in a hen pheasant. It measured when 
 fresh 2.3 inches in greatest length, 1.1 in breadth, and the same 
 in depth. It was very irregular in form, and was roughly 
 divided into three principal lobes, which were united at their 
 bases, and were subdivided into many smaller lobes ; the whole 
 presented the general sulcated appearance of a human brain on 
 a smaller scale. 
 
 The ovary seemed to be almost entirely absorbed ; nothing 
 resembling its usual granular appearance w^as visible ; and the 
 tumor rested consequently directly upon the kidneys, a fold of 
 peritoneum alone intervening. Though no ovary was visible, 
 the left oviduct was convoluted as much as it would be in the 
 earlier part of the breeding season, but this, of course, was not 
 healthy excitement, but due to the inflammation of the organs. 
 The right oviduct presented its usual aborted appearance. 
 
 On making a transverse section of the tumor, the interior was 
 seen to be quite solid, and in no degree cystic or alveolar ; nor 
 was there, as might have been thought likely, any tendency to 
 a concentric growth, but, on the contrary, bundles of fibres were 
 seen faintly to radiate from the point of attachment of the 
 tumor. 
 
 The minute anatomy was difficult to determine, owing to the 
 necessity of employing a high power. There were visible fat- 
 cells (by far the largest), granule-cells, and nucleated cells,
 
 OYAKIAN TUMORS, CONDITIONS WHICH SIMULATE THEM. 231 
 
 which I regard as resembling those found in tubercle — the last 
 named being very numerous and irregular in shape and size. 
 Interspersed were minute fibres, but these were rare ; and lastly, 
 diverging from the base of attachment of the tumor, were bun- 
 dles of fibres, very irregular in shape. To these is due the 
 radiated appearance of the section. They are unstriated mus- 
 cular fibres, and seem to be the only remains of the original 
 ovary. 
 
 This diseased ovary is only the most conspicuous part of a 
 general tubercular affection which pervaded the whole of the 
 viscera — the liver, pancreas, omentum, and intestines being all 
 distinctly more or less involved. 
 
 I was under the impression that the tumor was cancerous, 
 from the great resemblance under the microscope to medullary 
 cancer of the human ovary ; and my thanks are due to Profes- 
 sor Turner, who was kind enough to suggest that the tumor was 
 probably tubercular, the correctness of which opinion was at 
 once verified by means of dilute acetic acid.
 
 CHAPTER V. 
 ovaeioto:my. 
 
 In addition to works and papers already referred to, the fol- 
 lowing have been consulted: 
 
 Demonstration eines Praparates von doppelseitiger Achsendrehung der Ovarien. 
 
 Veit. Arch. f. Gyn., Vol. XIII. 
 Ueber Ovariotomie bei Kindern. Schwartz. Arch. f. Gyn., Vol. XIII. 
 Zur Statistik der Krankheiten der Ovarium. Runge. Schmidt's Jahrbuch, Vol. 
 
 CLXXVIII. 
 Peritonseale Metastasen eines Eierstocks dermoids. Kolaczek. Virchow's Archives, 
 
 Vol. LXVII. 
 Ruptur der Ovarialcyste. Nepuen. Centralblatt f. Chir. , Vol. II. 
 Tod nach Function der Ovarialcyste. Boissier. Centralblatt f. Ohir., Vol. I. 
 Spontane Ruptur der Ovariengeschwulste. Kryzan. Centralblatt f. Chir., Vol. III. 
 Stielbehaudlung Ovariotomie. KoVACS. Centralblatt f. Chir., Vol. III. 
 Elektrische Behandlung Ovarialtumoren. Clemens. Centralblatt f. Chir., Vol. IV. 
 Exstirpation der Ovarien bei starken Menorrbagie. Stahl. Centralblatt f. Chir., 
 
 Vol. IV. 
 Ovariotomie. Tait. Wegen XJterinblutungen. Centralblatt f. Chir., Vol. VI. 
 Ovariotomien in Italien. PERUZzr. Centralblatt f. Chir., Vol. VI. 
 Chirurg. Bemerk. uber die Peritonealhohle mit Besonderer Beiucksichtigung der 
 
 Ovariotomie. Wegner. Arch, fur Klin. Chir. , Vol. XX. 
 Ein Fall von Laparo-Hysterotomie sammt Exstirpation beider Ovarien, Heilung. 
 
 WoLFLER. Archives fur Klin. Chir. , Vol. XXI. 
 Ovarialcysten 5 Falle. Wolfler. Arch, fur Klin, ("hir.. Vol. XXI. 
 Kyste de I'Ovaire, I'enleve par le vagin. Davis. Bulletin General. 1875. Vol. I, 
 Ovariotomie. Ferrier. Bulletin General. 1875. Vol. I. 
 Ovariotomie d'un kyste ponctionne 24 fois. Bouger. Bulletin General. 1875. 
 
 Vol. II. 
 Ovariotomie dans le sud-ouest de la France. Duplong. Bulletin General. 1876. 
 
 Vol. I. 
 Ovariotomie double. Bulletin General. 1876. Vol. I. 
 Ovariotomie (Observations). Tessier. Bulletin General. 1876. Vol. IL 
 Contribution a I'aide de I'Ovariotomie. Dezanneau. Bulletin General, January 15, 
 
 1880. 
 Ovariotomie. Bulletin General. Vols. II. 1878 and 1879. 
 Ovariotomie Indicationen, etc. Koeberle. Centralblatt fiir G.yn.^^ Vol. XI. 
 Ovariotomie Stielbehaudlung. Baum, etc. Cent. f. Gyn., Vol. XI. 
 Ovariotomie Tetanus. Parvin. Cent. f. Gyn., Vol. XI. 
 Ovariotomia triplex bei Ueberzahl von Ovarien. Winkler. Arch, f . Gyn. , Vol. XIII.
 
 OVAEIOTOMY. 233 
 
 Uber Ovariotomie bci Kindern. Schwartz. Arch. f. Gyn. , Vol. XIII. 
 Balneotherapie. Eatziindung der Ovarium. Flechsig. Schmidt. Vol. CLXX. 
 Ovarium Krebs, auf Uterus u. Rectum iibergreifend " Obstet. Trans." 1876. Schmidt, 
 
 Vol. CLXXVII. 
 Fall Ovariotomie. Runge. Schmidt. Vol. CLXXVIII. 
 Death from Ovarian Cancer. PuiLiPSON. Lancet, 1877. Vol. I. 
 Laceration of the Bowel in Ovariotomy. Cha.mbebj. Lancet, 1877. Vol. II. 
 Exceptionally Difficult Case of Ovariotomy. Tait. Lancet. 1877. Vol. II, 
 After History of a Case of Ovariotomy. Tait. Lancet, 1877. Vol. IL 
 Ovariotomy in France. Beclakd. Lancet, 1878. Vol. I. 
 Ovariotomy. Who shall Perform it ? Rudford, Lancet. 1878. Vol.1. 
 Ovariotomy. Who shall and Who shall not Perform it ? Editor. Lancet, 1878. Vol. 
 
 IL 
 Wound of Bladder in Ovariotomy. Ecstache. Brit. Med. Journal, 1879. Vol. II. 
 The Scotsman on Ovariotomy. Editor. Brit. Med. Journal, 1819. Vol. II. 
 Parthogenetic Development of Cysts in the Ovary. Tait. Brit. Med. Journal, 1879. 
 
 Vol. IL 
 Castration of Women. ScEUCKiNG. Med. Record. November, 1879. 
 Perforating Ulcer of Ilium after Ovariotomy. Dor ax. Lancet, 1879. Vol. I. 
 Ovariotomy during Peritonitis. Tibbets. Med. Times, 1874. Vol. I. 
 Ovariotomy under Difficulties. Stevens. Med. Times, 1874. Vol. I. 
 Historical Sketch of Ovariotomy. J.\ckson. Med. Times, 1874. Vol. I. 
 The First Operation for Ovariotomy. Anon. Med, Times, 1874. Vol. II. 
 Ovariotomy at the London Surgical Home. Bakeh Brown. Lancet, 1862. 
 Birth of Triplets after Ovariotomy. Balding. Med. Times, 1874. Vol. II. 
 Diagnosis of Ovarian Disease. Baccelli. Med. Times, 1877. Vol. I. 
 Lister's Method in Ovariotomy. Sims. Med. Times, 1877. Vol. I. 
 Ovariotomy. Billroth. Med. Times, 1877. Vol. II. 
 Ovariotomy during Pregnancy. Wells. Times, 1877. Vol. II. 
 Elastic Ligature in Ovariotomy. Kleberg. Med. Times, 1877. Vol. II. 
 Normal Cases of Ovariotomy. Hegar and Battey. Med. Times, 1877. Vol. II. 
 Ovariotomy. Sims. Med Times, 1877. Vol II. 
 
 Double Specimens of Ovarian Cysts Edis. Med. Times, 1878. Vol I. 
 Unsuccessful Cases of Ovariotomy. Knowsley Thornton. Med. Times, 1873. 
 
 Vol. II. 
 Amount of Life saved by Ovariotomy. Wells. Med. Times, 1878. Vol. II. 
 Prohibition of Ovariotomy at Guy's Hospital. Editor. Med. Times, 1878. Vol. II. 
 Monument to the " Father of Ovariotomy." Boston Journal. Med. Times, 1870. 
 
 Vol. II. * 
 
 Ovariotomy. Treatment of Pedicle. Spiegelberg. Med. Times, 1879. Vol. I. 
 Section de I'urethre pendant Ovariotomie. Nussbaum. Ann. de Gyn. Vol. VI. 
 Ovariotomie chez les femmes enceintes. Valcourt. Ann. de Gyn. Vol. VIII. 
 Ovariotomie. Traitement du Pedicule. Netzel. Ann. de Gyn Vol. IX. 
 Indications et contre-indications de I'Ovariotomie. Duplay. Ann. de Gyn. Vol. X. 
 Tumeur solide des deux Ovaires. Ferrier and Rozzi. Ann. Gyn. Vol. XI. 
 Hernies de rOvaire dans I'antiquite. HouzE. Ann. Gyn. Vol. XI. 
 Double Hernia Ovarialis. Wirth. Archiv. fiir Gynekologie. 1877. 
 Amputation utero-ovarique. Tarnier. Ann. Gyn. Vol. XI. 
 New Clamp for Ovariotomy. Dawson. Amer. Journ. Obst. May, 1875. 
 New Ligature for Pedicle in Ovariotomy. Hosmer. Amer. Journal Ob.'-t. May, 1875. 
 Diagnosis of Ovarian Tumors. Cuadwick. Amer. Journal Obst. Vol. IX. 
 Normal Ovariotomy. Battey. Amer Journal Obst. Vol. IX. 
 Therapeutics of Ovarian Tumors. Feiber. Amer. Journal Obst. Vol. IX.
 
 234 DISEASES OF THE OVAKIES. 
 
 Ovariotomy on a Girl of Thirteen. Koeberle. Amer. Journal Obst. Vol. IX. 
 "No more Ovariotomy." Semeledek. Amer Journal Obst. Vol. IX. 
 Ovariotomy. Fibroma of the Ovary. Atlee. Amer. Journal Obst. Vol. IX. 
 Dermoid Cyst of Ovary. Ferkiek. Amer. Jourual Obst. Vol. IX. 
 Ovariotomy in a Child of Four. Schwakz. Amer. Journal Obst. January, 1879. 
 Fluid of Polycystic Ovarian Tumors. Buckham. Amer. Journal Obst. April, 1879. 
 Multilocular Cysto-sarcoma. Engelmann. Amer. Journ. Obst.. Apr 1, 1879. 
 Ovarian Cysts in a Case of Extra-Uterine Fcetation. ScoTT. Obst. Trans. Vol. XV. 
 Suppurating Tumor of Left Ovary. Oswald. Obst. Journ., 1875. Vol. III. 
 Drainage of Ovarian Cysts. Delore. Obstet. Journ. Vol. IV. 
 Ligature of Ovarian Pedicle. Howe. Obstet. Journ. Vol. IV. 
 Ovariotomy under Carbolic Spray. Bau.m. Obst. Journ. Vol. IV. 
 Ovariotomy, Treatment of Pedicle. Keith. Obst. Journ. Vol. IV. 
 Ovariotomy. Post-mortem Seven Years After. Hr.ME. Obst. Journ. Vol. IV. 
 Dermoid Tumor of the Ovary. FoULls. Obst. Journ. Vol. IV. 
 Rupture of Ovarian Cyst during Labor. Quern. Obst. Journ. Vol. V. 
 Vaginal Drainage in Ovariotomy. Olsiiausen. Obst. Journ. Vol. V. 
 Abdominal Drainage in Ovariotomy. Hildebrandt. Obst. Journ. Vol. V. 
 Menstruation after Double Ovariotomy. Verneuil and Ferrier. Obst. Journ. 
 
 Vol. V. 
 Removal of Ovaries. Chambers. Ob^t. Journ. May, 1879. Vol. VI. 
 Diagnosis of Large Ovarian Tumors. Schultze. Obst. Journ. , October, 1877. 
 Dermoid Cyst of Ovary. Miller. Glasgow Medical Journal, 187G. 
 Tapping of Ovarian Cysts. Kidd. Dublin Medical Journal, 1874. 
 Ruptured Ovary. Canning. Dublin Medical Journal, 1878. 
 Controlling Temperature after Ovariotomy. Thomas. Dublin Medical Journal, 1879. 
 
 January to June. 
 One Hundred and Ninety Cases of Ovariotomy. Keith. Edinburgh Medical Jour- 
 nal, 1874-5. 
 Ovariotomy in Cases of Suppurating Cyst. Keith. Edinburgh. Medical Journal, 
 
 1874-5. 
 Extirpation of Kidney. Campbell. Edinburgh Medical Journrl. Vol. XIX. 
 Twin Pregnancy after Ovariotomy. Mazolo. Edinburgh Medical Journal. Vol. XIX. 
 Ovariotomy with Pregnancy. Hillas. Edinburgh Medical Journal. Vol. XXI. 
 Ovariotomy under Difficulties. Stevens. New Y'ork Medical Journal Vol. XIX. 
 Case of Normal Ovariotomy. Sabine. New York Medical Journal. Vol. XXI. 
 Ovariotomy in Edinburgh. Keith. New York Medical Journal. Vol. XXII. 
 Actual Cautery in Ovariotomy. Keith. New York Medical Journal. Vol XXIII. 
 Removal of Ovaries for Epilepsy. Battey. l^ew York Medical Journal. Vol. 
 
 XXIV. 
 Purulent Cyst of Ovary. J.\cobl New York Medical Journal. Vol. XXV. 
 Multilocular Complicated Ovarian Cyst. New York Medical Journal. Vol. XXVI. 
 Rupture of Ovarian Cysts into Intestines. New York Medical Journal. Vol. XXVII. 
 Ovarian Cyst Treated by Electrolysis. Cutter. New York Medical Journal. Vol. 
 
 XXVII. 
 Enucleation of Ovarian Tumor. Miner. American Medical Journal. Vol. LXVII. 
 Normal Ovariotomy. Thomas. American Medical Journal. Vol. LXVII. 
 Vaginal Ovariotomy. Gilmore Reeve. American Medical Journal. Vol. LXVII. 
 Diagnosis of Subacute Ovaritis. Tilt. American Medical Journal. Vol. LXVII. 
 Ovaries from Case of Normal Ovariotomy. Thomas. American Medical Journal. 
 
 Vol. LXVIII. 
 Ovariotomy Compared with Hysterotomy. RiCHET. American Medical Journal. 
 
 Vol. LXVIIL
 
 OVARIOTOMY. 235 
 
 Ovulation without Menstruation. Sinett. American Medical Journal. Vol. LXVIII. 
 Ovarian Cyst Cared by Puncture. Vast. American Medical Journal. Vol. LXX. 
 Ovarian Cyst, Menstruation from Pedicle. American Medical Journal. Vol. LXXf. 
 Dermoid Ovarian Cysts. Griffiths and Bern UTZ. American Medical Journal. Vol. 
 
 LXXIII. 
 Pelvic Adhesions in Ovariotomy. Attlee. American Medical Journal. Vol. LXXIII. 
 Ovariotomy During Peritonitis. MUNDE and Tait. American Medical Journal. Vol. 
 
 LXXV. 
 Electrolysis in Ovarian Tumors. MuNDE. American Medical Journal. Vol. LXXVI. 
 Ovariotomy, Ligature of Pedicle Complete. Doran. American Medical Journal. 
 
 Vol. LXXVII. 
 Drainage of Ovarian Cysts. Stimson. American Medical Journal. July, 1879. 
 Considerations sur rOvariotomie. Wegner. Arch. Gen., 1877. Vol. I. 
 Ovariotomie norniale. Lutaud. Arch. Gen., 1879. Vol.1, 
 Amputation utero Ovarique. Imbert. Arch. Gen., 1879. Vol. I. 
 Fifty Cases of Ovariotomy. Tait. Birmingham Med. Review. Vol. VII. 
 Normal Ovariotomy. Editor Birmingham Med. Review. January, 1879. 
 Ovariotomy, Ligature of the Pedicle. DoRAN. iSt. Bartholomew's Hospital Reports, 
 
 1877. 
 Ovariotomy, Ligature of the Pedicle. Doran. St. Bartholomew's Hospital Reports, 
 
 1878. 
 Successive Stages of Ovariotomy. Doran. St. Bartholomew's Hospital Reports, 
 
 1878. 
 Ovaries Removed by Operation. Pathological Transactions, 1874. 
 Ovarian Tumor in Girl of Ten. Dickinson. Pathological Transactions, 1874. 
 Cancers of Both Ovaries and Breasts. CocPLAND. Pathological Transactions, 
 
 1876. 
 Ovariotomy in Hospitals. Editor British Medical Journal, 1874. Vol. I. 
 Ovariotomy in a Child. Wells. British Medical Journal, 1874. Vol. I. 
 Ovariotomy in Leeds Infirmary. Wiieeliiouse. British Medical Journal, 1874. Vol. I. 
 The First Ovariotomy.. Jackson. British Medical Journal, 1874. Vol. I. 
 Tumor of the Ovary Removed by Enucleation. BURNIIAM. British Medical Journal, 
 
 1874. Vol. i. 
 Tumor of Kidney Simulating Cystic Ovary. British Medical Journal, 1874. Vol. I. 
 Disease of Ovary. Campbell. British Medical Journal, 1874. Vol. I. 
 Fluids in Pelvis after Ovariotomy. Keith. British Medical Journal, 1875. Vol. I. 
 Dropsy of Ovary. Smith. British Medical Journal, 187G. Vol. I. 
 Suppurating Tumor of Ovary. Oswald. British Medical Journal, 187-3. Vol. I. 
 Malignant Disease of Ovary. Cii.vrteris. British Medical Journal, 1876. Vol. I. 
 Prolapse of Cyst of Ovary. Stocks. British Medical Journal, 1876. Vol. I. 
 Mortality after Ovariotomy in Dublin. Kidd. British Medical Journal, 1876. Vol. II. 
 Enucleation of Cysts of Ovary. Miner. British Medical Journal, 1876. Vol. II. 
 Ovariotomy in the London Hospitals. Wells. British Medical Journal, 1877. Vol. 1. 
 Ovariotomy in Vienna. Billroth. Briti.sh Medical Journal, 1877. Vol. I. 
 Ovariotomy in Dublin Hospitals. Atthill. British Medical Journal, 1877. Vol. I. 
 Clinical Lecture on Ovariotomy. Heath. British Medical Journal, 1877. Vol. I. 
 Aspiration of Cysts of Ovary. Edis. British Medical Journal, 1877. Vol.1. 
 Growth of Cysts of Ovary. Tait. British Medical Journal, 1877. Vol. L 
 Spontaneous Cure of Ovarian Cyst. Quinby. Medical Record, 1876. 
 Vaginal Ovariotomy. Wing. Medical Record, 1877. 
 Pus in Ovarian Fluids, ('hadwick. Medical Record, 1877. 
 Medullary Sarcoma of Left Ovary. Clemens. Biennial Ret., 1874. 
 Ovarian Menorrhagia. Meadows. British Medical Journal. July 12, 1879.
 
 236 DISEASES OF THE OVAEIES. 
 
 Ovarian Tumor Removed from Child of Two Years and Eleven Months. Kidd. Dub- 
 lin Medical Journal, February, 1879. 
 
 Ovarian Cysb in a Child of Three Years and Four Mouths. New Yoik Medical 
 Journal, January, 1880. 
 
 Relation of Diseases of Ovarian Blood-vessels to Ovarian Cysts. Nokggerath. New 
 York Medical Journal, January, 1879. 
 
 Diagnosis of Ovarian Tumors. Tait. New York Medical Journal, April, 1880. 
 
 Considerations a propos de I'Ovariotomie. Tillaux. Annales de Gynecologie. 
 Ma;ch, 1879. 
 
 Relations of Disease of Blood-vessels of Ovary to Ovarian Cysts. Noeggeratii. 
 American Journal of Obstetrics. January, 1880. 
 
 Ovarian Cyst in a New-born Child. Thomas. American Journal of Obstetrics. Jan- 
 uary, 1879. 
 
 General Peritonitis — Ovaritis with Abscess. LusK. American Journal of Obstetrics. 
 January, 1880. 
 
 Ein Fall von Psammocarcinom des Ovarium. Flaischlen. Virchow's Arch., Jan- 
 uary, 1879. 
 
 Krebs (auf beiden Seiten). Breisky. Schmidt. January, 1879. 
 
 Zur diagnostischen Punktion bei abdom. Cysten. Spiegelberg. Schmidt. April, 
 1880 
 
 Ueber die Exstirpation extra peritoneal gelogerter Ovarial und parovarial geschwulste. 
 MuLLER. Schmidt. April, 1880. 
 
 Antiseptic Theory and Ovariotomy. (Paper and discussion.) Tait. Lancet. Feb- 
 ruary 14th ; also Medical Times, February 38, 1880. 
 
 Ovariotomy; Abscess Opening into Intestine. Moore. Lancet, February 28, 1880. 
 
 Two Cases of Oophorectomy. Ewkn«. British Medical Journal, January 81, 1880. 
 
 Case of Ovariotomy in the Sixth Month of Pregnancy. Galabin. British Medical 
 Journal, March 13. 
 
 Ovariotomy in New York and London. Sims, etc. British Medical Journal, 1877. 
 Vol. II. 
 
 Drainage in Ovariotomy. Bantock. British Medical Journal, 1877. Vol. II. 
 
 Ovariotomy During Pregnancy. British Medical Journal, 1877. Vol. II. 
 
 Suppuration of Tumor of Ovary. Bennet. British Medical Journal, 1878. Vol. I. 
 
 Lectures on Ovariotomy. Wells. British Medical Journal, 1878. Vol. II. 
 
 Ovariotomy in General Hospitals. Editor. British Medical .Journal, 1878. Vol.11. 
 
 Ovariotomy During Pregnancy. Smith. British Medical Journal, 1878. Vol. II. 
 
 Ovariotomy Before and After Antiseptics. Keith. British Medical Journal, 1878. 
 Vol. II. 
 
 Remarks on Ovariotomy. Nossbaum. British Medical Journal, 1878. Vol. II. 
 
 Cyst of Ovary. Hayes. British Medical Journal, 1878. Vol, II. 
 
 Opinion on Ovariotomy. Hunter. Medical Press, 1875. Vol. I. 
 
 Vitality of Ova. Colasantir. Medic il Press, 1876. Vol. I. 
 
 Dispersion of Ovarian Cysts by Electricity. Eurenstein. Medical Press, 1877. Vol.1. 
 
 Complication in Ovariotomy. MiCHAUX. Medical Press, 1877. Vol.1. 
 
 Ovariotomy and Hysterotomy. Richkt. Practitioner. Vol. XII. 
 
 Double Ovariotomy, Transfusion of Milk. Gaillard Thomas. Practitioner. Vol. 
 XX. (453). 
 
 Dermoid Tumors of Ovaries. Byford. Medical News and Library, 1878. 
 
 Sarcoma Mista^'en for Ovarian Tumor. Cremonksts. Medical Record, 1875. 
 
 Ovariotomy ; Battey's Operation. Yandell and McClellan. Medical Record, 1875, 
 
 Drainage in Ovariotomy. Pauli. Medical Record, 1875. 
 
 Ovtiriotoiny in a Girl of Thirteen. Koebekle Medical Record, 1876. 
 
 Ovariotomy during Septica3mic Fever. Peruzzi. Medical Record, 1876.
 
 OVARIOTOMY. 237 
 
 Ovariotomy during Pregnancy. Baxjm. Medical Record, 1876. 
 
 Tetanus after Ovariotomy. Bantock. British Medical Journal, April 17. 
 
 Summary of Fifteen Cases of Battey's Operation. Battey. British Medical Journal, 
 April 3, 1880. 
 
 Thomas Keith and Ovariotomy (paper on). Marion Sims. Boston Medical and 
 Surgical Journal, March 4, 1880. 
 
 Ovariotomy ; Death from Internal Hemorrhage. HOMANS. Boston Medical and Sur- 
 gical Journal, March 11, 1880. 
 
 Metro-Peritoneal Fistula in a Case of Successful Ovariotomy. Tait. Lancet, 1875. 
 Vol. I. 
 
 Ovarian Tumor Simulating Extra-uterine Pregnancy. Tait. Lancet, 1875. Vol.11. 
 
 Results of the Cautery in the Treatment of the Pedicle in Ovariotomy. Keitu. Lan- 
 cet, 187G. Vol. I. 
 
 Case of Battey's Operation. Engelmann. Boston Medical Journal, May 13, 1880. 
 
 On Oophorectomy. Savage. Obstetric Journal, May, 1880. 
 
 Oper ition de Porro (Ca-^es). Championniere. Annales de Gyn., April, 1880. 
 
 Ascite simulant un kj'ste de I'ovaire. Hinze. Annales de Gyn., April, 1880. 
 
 High Temperature after Aseptic Ovariotomy. Thornton. British Medical Journal, 
 May 1, 1880. 
 
 Listerian Method in Ovariotomy. Tait. Medical Times, June 26, 1880. 
 
 Three Cases of Ovariotomy during Pregnancy. PippingskOld. American Journal 
 of Obstetrics, April, 1880. 
 
 Earliest Age at which Ovarian Cysts are Found. Jenkins. American Journal of Ob- 
 stetrics April, 1880 
 
 Intestinal Obstruction Pedicle of Ovarian Cyst around Ileum. Henry. American 
 Journal of Obstetrics April, 1880. 
 
 Battey's Operation in Epileptoid Affections. Sims. Mec'ical Record. New York, 
 June 5, 1880. 
 
 True Import of Oophorectomy in Epilepsy, etc. Fallen. Medical Record. New 
 York, June 5, 1880. 
 
 Ovarian Cyst repeatedly Ruptured. Meredith Lancet. December 20, 1879. 
 
 Drainage-tubes in Ovariotomy. Bantock. Med. Times. 1879. Vol. II., p. 24. 
 
 Etranglement interne— kyste ovarique. Julltard. Ann. de Gyn. January, 1880. 
 
 Case of Detached Ovary. Peaslee. Amerinan Journal of Obstetrics. Vol. XI. 
 
 Ovariotomy with Fibroid Tumor of Ovary. Goodell. American Journal of Obstet- 
 rics. Vol. XI. 
 
 Ovarian Cyst in an Infant. Leduc. New York Medical Journal, 1879. Vol., II. 
 
 An Account of a Drop.-y in the Left Ovary of a Woman, ag-ed Fiftv-eight, CureJ by a 
 Large Incision made in the Side of the Abdomen, by Dr. Robkrt Houston. 
 Philosophical Transactions. Vol. XXXIIL London, 1724. 
 
 Cases of Dropsical Ovaria, Removed by the Large Abdominal Section, by D. Henry 
 Walne, Surgeon. London, 1843. 
 
 Another Case by same Author. Medical Gazette, 1844. 
 
 History and Statistics of Ovariotomy. Lynam. Proceedings of Massachusetts Medi- 
 cal Society, 1855. 
 
 Removal of a Dropsical Ovarium by GEORGE Southam. London Medical Gazette, 
 1847. 
 
 Ovarian Dropsy. Dr. Frederick Bird. Medical Times and Gazette. Vols. XXIV , 
 XXV., and XXV L 
 
 Six Cases of Ovarian Dropsy. Dr. Jeapfreson. Medical Gazette, 1844. 
 
 The Results of all the Opentions Performed for the Extirpation of Diseased Ovaria 
 by the Large Incision, from September 12, 1842, to the Present Time. Charles 
 Clay, M.D. Manchester, 1848.
 
 238 DISEASES OF THE OVARIES. 
 
 Ovariotomy. J. Y. Simpson. Monthly Journal of Medical Science. January, 1846. 
 Removal of Diseased Ovaria, by Ephraim McDowell. Eclectic Repertory and 
 
 Analytic Review. Philadelphia, 1816. 
 Simpsou's Obstetric Works. Puiestley & Storer. Edinburgh, 1855. 
 Resultats Statistiques de L'Ovariouomie. E. KoEBERLE. Paris, 1868. 
 Thomas Keith and Ovariotomy. J. Marion Sims. New Yorlt, 1880. 
 Lettre d' Abraham Cypriauus. T. MiDDLETON. Amsterdam, 1707. 
 Beitriige zur VervoUkomraung der Heiikunde. Dzondi. Halle, 1816. 
 Histoire de la SociL-te Royale de Medicine. L'Aumonier. Vol. V., 1783. 
 De la Porte et Morand. Memoires de I'Academie de Chirurgie. Vol. II. 
 Ueber extirpation Krankhafter Eierstocke. HoPFER. Graefe and Walter's Journal. 
 
 Vol. XII. (for Chrysmar's case). 
 Medical Observations and Enquiries. William Hunter, 1762. 
 Lecture on Ovariotomy. Dr. Charles Clay. Edinburgh Medical Journal, 1857. 
 
 It is characteristic of every advance which has been made in 
 surgery, as in all other human affairs, that the early phases are 
 developed with extreme slowness, so that in perusing the history 
 of any surgical progress it is almost certain that we should have 
 to go a long way back to see the first germs of the movement. I 
 have, I believe, examined very exhaustively the literary history 
 of ovariotomy, but I can find no record of any deliberate attempt 
 to relieve a patient from ovarian dropsy by opening the abdomen 
 earlier than the year 1701. It is a singular and striking illus- 
 tration of the slow progress made by any new idea, that, so late 
 as 1861, an operation which was successfully performed by Rob- 
 ert Houstoun, of Glasgow, one hundred and sixty years before, 
 should have been characterized by one of the leading surgeons 
 of his time as an operation which ought to subject its perfor- 
 mer to a criminal indictment for manslaughter. I can, how- 
 ever, well remember, in the days when I was a student at Edin- 
 burgh, one of the favorite subjects for discussion in the students' 
 medical societies was the doubtful point of ovariotomy being a 
 justifiable operation, and now, when I find my mortality varying 
 from three to five per cent., it sometimes seems to me as if these 
 discussions were but ill-remembered dreams; for it must be ad- 
 mitted there is no important operation which has received the 
 same hostile criticism, the same searching scrutiny, or finally 
 has achieved the same triumphant admittance as ovariotomy. 
 Its critics have subjected it to a statistical ordeal through which 
 no other surgical operation has passed, and it is the only one 
 which has achieved a legitimate and complete establishment. 
 
 The merit of being the first to utter an opinion in favor of 
 the radical cure of ovarian dropsy has usually been ascribed to 
 William Hunter, but Houstoun's operation was performed seven- 
 teen years before Hunter's birth, and so far as the history of this 
 question has been unearthed, I think the whole merit must be
 
 OVAEIOTOMT. 239 
 
 given to the Glasgow surgeon. So important do I regard this as 
 being the first case, that I give at length what information I have 
 been able to obtain concerning this most interesting man and the 
 details of his operation. For much of this I am obliged to Mr. 
 Alexander Duncan, of Glasgow. 
 
 Robert Houstoun was the son of a Glasgow surgeon of the 
 same name, who held the office of Visitor of the Faculty of Phy- 
 sicians and Surgeons of Glasgow in 1GG9, and again in 1677, this 
 office being virtually that of President of the Surgeons. Robert 
 Houstoun the younger was regularly apprenticed to his father in 
 1665, this being before the days of the existence of any medical 
 schools in Scotland, and it is probable he had few other oppor- 
 tunities of making himself acquainted with the surgical art than 
 those afforded him by his seven years' apprenticeship to his 
 father. At its expiration he became a member of the Faculty 
 and began to practise in Glasgow as a "surgeon-apothecary," 
 or general practitioner. 
 
 In 1691 he was himself elected Visitor of the Faculty, an 
 honor which was more than once renewed, so that it becomes 
 perfectly clear that in his native city he was at a very young 
 age a person of distinction, and probably an operating surgeon of 
 large experience. In 1697 he took an active part in forming a 
 collection of medical works, which was the nucleus of the present 
 library of the Glasgow Faculty. The " list of such worthie per- 
 sonnes " as contributed to this collection, with the names of the 
 works gifted by each, has been preserved, and under Houstoun's 
 name stands a considerable list of donations. Of these some are 
 no longer in the library, but others of them, bearing his auto- 
 graph, are still to be found on its shelves. 
 
 In 1711 he appears to have contemplated the somewhat risky 
 step of retiring from general practice and limiting himself to the 
 work of a physician. Houstoun's is the first case in Glasgow of 
 such a practice, and his example was followed by only some 
 three or four others in the course of the eighteenth century, of men 
 withdrawing into the quiet of purely consulting practice after 
 having made their positions as general practitioners. To accom- 
 plish this object of his ambition Houstoun required to obtain 
 the degree of Doctor of Medicine, a distinction which had been 
 acquired by three or four of his tov/nsmen by residence abroad, 
 usually at Utrecht or Leyden. Houstoun, however, resolved to 
 gain his degree from the University of his native city, which had 
 the power of granting such degrees even though it had no medi- 
 cal school, and was entirely destitute of a medical faculty. In 
 1711 he applied to be admitted to examination for the degree, but 
 it does not appear that the University authorities cared to com-
 
 240 DISEASES OF THE OVARIES. 
 
 ply with his request, for we find in the Archives of tlie Univer- 
 sity a minute dated 31st December of tliat year, that " Mr. 
 Robert Houstoun, surgeon, who sometime agoe, applyed for the 
 Doctorat in Medicin did still insist that he might be examined 
 in order to his graduation. The Faculty considering that they 
 might still want Professors of Medicin doe appoint some of the 
 Physicians in the city to assist at the examination." Before this 
 extra-academical board Houstoun passed his trials successfully 
 on January 3, 1712, and Mr. Duncan has favored me with an 
 extremely interesting extract from the records of the examina- 
 tion of this remarkable candidate. 
 
 Shortly after graduating, and probably between the years 
 1713 and 1715, Houstoun seems to have found the field offered for 
 his ambition in Glasgow too restricted, and he was induced to 
 attempt the larger field of the English metropolis. In London 
 it is probable that he practised as a general practitioner, for in 
 the thirty-third volume of the ''Philosophical Transactions," 
 page 388, he mentions that he was engaged in the practice of 
 midwifery, and of course no London physician would be so en- 
 gaged at that time. All his published works tend, however, to 
 show that the bent of his mind still lay in the direction of sur- 
 gery, and chiefly of abdominal surgery. In 1720 he published a 
 controversial pamphlet entitled " Animadversions on a late 
 Pamphlet entitled Lithotomia Douglasiana," and in 1726 ap- 
 peared his " History of Ruptures and Rupture Cures." 
 
 In 1722 he contributed to the Royal Society "An Account of 
 a Case of Extra-Uterine Foetus, taken out of a Woman after 
 Death." In this case it is extremely noteworthy that he had 
 proposed to operate during the life of the patient, and his offer 
 had been declined; had it been accepted, this remarkable man 
 would have ranked as the first operator in such a case, and it is 
 possible he might have been the first successfully to interfere in 
 this displacement. In 1724 he read before the Royal Society the 
 case upon which his reputation was chiefly founded, and which 
 formed the first case of ovariotomy. For this paper he was 
 elected a Fellow of the Royal Society in the following year. He 
 died in London, on May 15, 1734, about the age of seventy, so 
 we may estimate that his birth took place about the year 1654. 
 Unfortunately, I have not been able so far to obtain any account 
 of his life and doings while in London, save that he practised 
 somewhere about what was then the West End. His case of 
 ovariotomy is entitled "An Account of a Dropsy of the Left 
 Ovary of a Woman aged Fifty-eight, Cured by a Large Incision 
 made in the Side of the Abdomen by Dr. Robert Houstoun," and 
 the following is the gist of his description of his operation:
 
 OVARIOTOMY. 241 
 
 " I found this tumor grown to so monstrous a bulk, that it en- 
 grossed the whole left side from the umbilicus to the pubes, and 
 stretched the abdominal muscles to a great degree. It drew 
 toward a point. From being obliged to lie continually on her 
 back, she was grievously excoriated, which added much to her 
 sufferings, which, together with a want of rest and appetite, had 
 greatly emaciated her. 
 
 "The operation of puncturing the abdomen being proposed, 
 she consented: accordingly, with an imposthume lancet I laid 
 open about an inch, but finding nothing issue I enlarged it two 
 inches, and even then nothing came forth but a little thin, yel- 
 lowish serum, so I ventured to lay it open about two inches 
 more. I was not a little startled after so large an aperture to 
 find only a glutinous substance bung up this orifice. The diffi- 
 culty was how to remove it : I tried my probe and endeavored 
 with my fingers, but it was all in vain, it was so slippery that it 
 eluded every touch and the strongest hold I could take. 
 
 "I wanted in this place almost everything necessary, but be- 
 thought of a very odd instrument, yet as good as the best in its 
 consequence, because it answered the end proposed. I took a 
 strong fir-splinter, such as the poor in that country use to burn 
 instead of candles; I wrapped about the end of this splinter some 
 loose lint, and thrust it into the wound, and by turning and 
 winding it I drew out above two yards in length of a substance 
 thicker than any jelly, or rather like glue fresh made and hung 
 out to dry; its breadth was above ten inches; this was followed by 
 nine full quarts of such matter as is met with in steatomatous and 
 atheromatous tumors, with several hydatides, of various sizes, 
 containing a yellowish serum, the least of them larger than an 
 orange, with several large pieces of membrane, which seemed to 
 be parts of the distended ovary. I then squeezed out all I could 
 and stitched up the wound in three places, almost equidistant ; 
 I was obliged to make use of Lucatellus' balsam, to cover a 
 pledget, the whole length of the wound, and over that laid sev- 
 eral compresses, dipped in warm French brandy; and because I 
 judged that the parts might have lost their spring by so vast 
 and so long a distention, I dipped in the same a napkin four times 
 folded and applied it over all the dressings, and with a couple of 
 strong towels which were also dipped, I swathed her round the 
 body, and then gave her an opiate medicine, which was ordered 
 to be repeated at intervals. 
 
 " She afterward mended apace, to the admiration of every one, 
 and lived in perfect health from that time, which was in August, 
 1701, till October, 1714, when she died in ten days' sickness." 
 
 It may be said that Houstoun began this operation with the 
 16
 
 242 DISEASES OF THE OVAEIES. 
 
 intention of doing little more than relieving the patient by a 
 tapping, but I presume that the first man who put a kettle on 
 the fire had no intention of evolving a steam-engine from the 
 simple process of boiling water ; yet the discovery of how to boil 
 water was by far the most important of all the phases through 
 which the invention of the steam-eiibgine has passed. There can 
 be no question from Houstoun's description that he had diag- 
 nosed a dropsy of the ovary and that he had to deal with a con- 
 dition which is often one of the most difficult that can be met 
 with in the performance of ovariotomy, and he completed his 
 operation by removing the cyst. Although he does not describe 
 his division of the pedicle, or his having tied it, it is almost cer- 
 tain that he did both. He certainly must have seen and divided 
 the pedicle, for he describes the disease as being of the left 
 ovary, therefore he saw the pedicle. Perhaps he tore it and it 
 did not need tying. That he performed a complete ovariotomy 
 is certain, from his having noticed secondary cysts as well as 
 from the recovery of his patient and the fact that she lived for 
 thirteen years afterward, in perfect health. 
 
 William Hunter and his brother John Hunter must have 
 known of Houstoun's case, for they were born and brought up in 
 the district in which it occurred, and William Hunter lived for 
 years in the city near which it was performed. They both ad- 
 vocated the theory of the performance of the operation, and 
 John Hunter is reported to have said : '' I cannot see any reason 
 why, when the disease can be ascertained in an early stage, we 
 should not make an opening into the abdomen and extract the 
 cyst. Why should not a woman suffer spaying as other ani- 
 mals do ? The merely making an opening into the abdomen 
 would never be followed by death in consequence of it ? " 
 
 Their friend John Bell, who practised in Edinburgh from 
 1790 till 1816, also pronounced in favor of its performance, but 
 he is not known to have done anything toward trying it himself, 
 and it is to a young Scotchman,' who was a pupil of John Bell's 
 in 1793, that we owe the revival of the operation and its perform- 
 ance upon a scale which amounted to that of a legitimate experi- 
 ment. Ephraim McDowell has been honored by the medical 
 profession in America as the "Father of Ovariotomy," and 
 whether we admit the accuracy of the title or not, there can be 
 no doubt that it was in the backwoods of Kentucky that ab- 
 dominal surgery received one of its greatest impulses. In 1809 the 
 
 ' My American readers may object that McDowell was not born in Scotland. Of 
 this, however, we are not yet clear. At any rate, his father and mother were Scotch, 
 and at the time of his birth, 1771, the States did not exist.
 
 OVARIOTOMY. 243 
 
 second ovariotomy was performed successfully and the patient 
 survived it thirty-two years. In 1817 Dr. McDowell published an 
 account of these and of two other cases he had performed, and, as 
 might be expected, his statements were received with general 
 incredulity. The editor of the British and Foreign Medical and 
 Chirurgical Revieiv was bold enough to distinctly deny the credi- 
 bility of McDowell's statements, but in 1827, when the authen- 
 ticity of the accounts had been established beyond doubt, he had 
 the manliness to "beg pardon of God and of Dr. McDowell of 
 Danville " for his hardiness. The operation was performed 
 twelve times in all by Dr. McDowell, with a mortality of thirty- 
 three per cent. , and in one other case he failed to complete the 
 operation. 
 
 Lizars tells us that about 1816 Dr. McDowell sent his manu- 
 script to John Bell, at Edinburgh, for his perusal. At that time 
 the great surgeon had gone to Rome, suffering from his fatal 
 illness, and the manuscript was read by John Lizars, who was 
 doing John Bell's work. This accounts for Lizars being the first 
 to follow in Houstoun's footsteps in Scotland, and it affords a 
 curiously sequent history of the early phases of this notable sur- 
 gical success. 
 
 In 1822, Nathan Smith, of New Haven, performed an operation 
 successfully, and in 182.") Lizars made his first attempt, but un- 
 fortunately he had made a mistake and there was no tumor. 
 Nathan Smith's case was undoubtedly one of parovarian cyst, 
 and the operation was therefore not an ovariotomy at all. It is 
 notable, however, for the facts that he used the short incision and 
 the short ligature. The curious fact that so many of these early 
 successful cases were parovarian tumors makes me believe that 
 a great many more true ovariotomies were done, of which there 
 are no records, for they probably all died. Parovarian cysts 
 now are removed without any risk at all. I have never lost a 
 single case. It is therefore very likely that they formed the 
 early successes. On February 27, 1825, Mr. Lizars removed 
 an ovarian tumor successfully, using the long ligature. On 
 March 22d of the same year he removed another, using the 
 short ligature, but his patient died. In his fourth case he could 
 not remove the tumor, but the patient recovered from the incom- 
 plete operation. He concludes his account of these cases with 
 the remarkable sentence: "From these cases, it appears that 
 there is little danger to apprehend in laying open the abdominal 
 cavity; and that in diseased ovarium, extra-uterine conceptions, 
 foetus in utero, with deformity of the pelvis preventing embryul- 
 cia, aneurism of the common or internal iliac arteries, or of 
 the aorta, volvulus, internal hernia, and foreign bodies in the
 
 244 DISEASES OF THE OVARIES, 
 
 stomach threatening death, we should have recourse early to 
 gastrotomy. The delay in such cases is more dangerous than 
 the operation." It has taken fifty years to establish the justice 
 of this opinion. 
 
 Dr. Granville, of London, operated twice in 1827, and it is gen- 
 erally stated that both of his cases were unsuccessful, but in a 
 volume of notes made by the late Dr. T. H. Tanner, now in my 
 possession, and written in his own remarkably neat writing, I 
 have found a note to the effect that one of Dr. Granville's cases, 
 performed March 21, 1827, was successful, but I do not know 
 upon what authority this note is made. 
 
 For some ten or twelve years after the death of McDowell, 
 and after the failures of Lizars, ovariotomy seems by common 
 consent to have been discontinued. In March, 1836, Dr. Jeaffre- 
 son, of Framlingham, removed a parovarian tumor successfully 
 through an incision only an inch and a half long {" Transactions 
 Provincial Medical Association, 1837''), and it is an interesting 
 fact that Mr. R. C. King, of Saxmundham, assisted at this opera- 
 tion, for he shortly afterward described two cases of successful re- 
 moval of similar tumors. In 1838, Mr. Crisp, of Harleston, and Mr. 
 West, of Tunbridge {Lancet, 1837-8), also had successful cases, but 
 they were clearly all parovarian, and not ovarian tumors. On 
 November 6, 1842, Mr. D. Henry Walne performed three opera- 
 tions, all of which were successful, and published them as ovari- 
 otomies; but, singularly enough, in not one of these cases was the 
 tumor removed an ovarian cystoma. Mr. Walne gives a figure 
 of the first of his cases, and he so thoroughly describes the ap- 
 pearances of the other two that no doubt can exist that they 
 were parovarian cysts, and it is not clear whether he did or did 
 not remove the ovaries with them. On October 19, 1843, he re- 
 moved a tumor which was undoubtedly of ovarian origin, but 
 unfortunately the patient died. His method of operating was 
 very curious, and to us now would seem very ghastly, but still he 
 deserves the credit of a pioneer. He tells us his incisions were 
 fourteen or fifteen inches long, and that they were extended bit 
 by bit until the tumor slipped out of them; that is to say, a paro- 
 varian cyst, which might have been removed by a two-inch in- 
 cision after being tapped, was allowed to deliver itself, with its 
 wall unbroken, through an incision which was made large 
 enough to accommodate it. 
 
 On September 27, 1842, Dr. Charles Clay, of Manchester, who 
 may in all truth be regarded as the " Father of Ovariotomy " as 
 far as Europe is concerned, performed his first operation for the 
 removal of a diseased ovary. He had, on the twelfth of the same 
 month, performed another operation, but here again there is
 
 OVAKIOTOMY. 245 
 
 abundant evidence to show that a parovarian was mistaken for 
 an ovarian tumor. Previous to September, 1842, we have there- 
 fore records of only two ovariotomies, properly so called, in this 
 country, those of Houstoun and Lizars. 
 
 In 1843, Mr. Aston Key removed both ovaries, and Mr. Bransby 
 ■Cooper also tried the operation in that year, but it was not till 
 1844 that there was a successful case in London, operated on by 
 Dr. Frederick Bird, followed by one in the practice of Mr, Lane. 
 In the provinces, however, many successful cases had been done, 
 and the metropolis was, not for the only time, behindhand. Dr. 
 Clay continued to operate with very remarkable success for 
 many years until he had performed three lumdred and ninety- 
 five operations with one hundred and one deaths, his total mor- 
 tality being therefore about twenty-five per cent. His operations 
 were witnessed and alluded to by some of the most distinguished 
 practitioners of the time, and yet Clay has received an amount 
 of adverse criticism, and his statements have been received with 
 an incredulity which is as undeserved as it is unworthy of 
 those from whom it came, and which arose solely from the fact 
 of his being a provincial surgeon. Looking back upon the work 
 of a generation now almost passed, from a standpoint altogether 
 free from personal bias, I have no hesitation whatever in ascrib- 
 ing to Dr. Clay by far the larger share of the credit which arises 
 from the enormous advances made in abdominal surgery during 
 the last forty years. It is quite true that McDowell was the first 
 to do a. number of ovariotomies, and it is equally true that 
 Houstoun was the first successfully to remove a diseased ovary, 
 but it was Clay, of Manchester, who first showed that ovari- 
 otomy could be made an operation more justifiable by its results 
 than any of the major operations of surgery. His methods were 
 imperfect, as are the methods of all pioneers, but it was upon 
 his work that the foundation was laid for all those brilliant re- 
 sults we now attain. I say this with all the more readiness now 
 that Dr. Clay is far advanced in life, and that but lately a most 
 unfair and ungenerous attempt has been made to deprive him of 
 his just merit, though perhaps I might have left it unsaid, as 
 Dr. Clay has shown himself quite capable of his own defence. 
 In Sir J. Y. Simpson's Lectures, published in the Medical Times 
 and Gazette, 1859-61, there is the following evidence on behalf 
 of Dr. Clay: "Indeed, the revival of it is principally due to the 
 exertions and example of Dr. Clay, of Manchester, who has 
 himself operated now in ninety-three cases." Bryant, in his 
 book on " Ovariotomy" (18G7), entitles Dr. Clay '' the first great 
 apostle of ovariotomy in this country." Peaslee remarks in his 
 work on ''Ovarian Tumors," "to him, more than to all other
 
 246 DISEASES OF THE OVARIES. 
 
 operators the credit belongs of having placed the operations of 
 ovariotomy, on a sure foundation." 
 
 One of the most conspicuous defects of his method of pro- 
 ceeding was the employment of what is called the long liga- 
 ture — that is to say, he tied the pedicle, returned it into the ab- 
 domen, and left the ligatures hanging out of the wound, as was 
 done by McDowell and Walne. Had he cut these ligatures 
 short, and completely closed the wound, I have no doubt that 
 instead of having a mortality of twenty-five per cent, it would 
 speedily have fallen to six or eight per cent. 
 
 The great improvement which was effected upon Clay's 
 method was that which, curiously enough, had been employed 
 twenty years before by Nathan Smith, but which was neglected 
 until reintroduced and firmly established by the late Mr. Baker 
 Brown, and to this most able but most unfortunate surgeon I un- 
 hesitatingly award the position of having achieved the second 
 great advance in abdominal surgery. He began to operate in 
 1851, and his career ended in 18G7. He established the short in- 
 cision, the intraperitoneal method of dealing with the pedicle, 
 the use of the actual cautery for its treatment, and the complete 
 closure of the abdominal wound. Between May, 1865, and Sep- 
 tember, 18G7 (that is, during the time when he employed the 
 cautery), he performed forty operations upon these principles, 
 with four deaths, or a mortality of ten per cent. During the 
 same period Mr. Spencer Wells operated one hundred and one 
 times with twenty-six deaths; or a mortality slightly over twenty- 
 five per cent. Yerily ovariotomy would liave had a very differ- 
 ent history during the last fourteen years if Mr. Baker Brown 
 had not fallen a victim to his own folly, or professional jeal- 
 ousy — for opinions differ very much as to the cause of his death. 
 His methods, again, were in many respects faulty, and have 
 since been immensely improved upon; but I give these details 
 concerning the result of his practice because here again a most 
 unfair attempt has been made to deprive a man of the credit he 
 has deserved; and however much Mr. Baker Brown's actions in 
 other respects are to be deplored, and however much he may or 
 may not have deserved his sudden and disastrous downfall, he 
 does deserve to rank second in order of English ovariotomists. 
 
 The following letter from Dr. T. Keith {British Medical Jour- 
 nal, July 31, 1880) gives very important evidence upon this point 
 in the history of ovariotomy: 
 
 "Simple experience with the clamp alone did little to dimin- 
 ish this mortality ; for. in Mr. Wells' published eight hundred 
 cases, the death-rate in the last three hundred was greater than 
 in the preceding three hundred. His results by the dropped liga-
 
 OVARIOTOMY. 247 
 
 ture were even worse— thirty-eight per cent. All over the fright- 
 ful mortality of one in four continued ! 
 
 "For some time past it has seemed to me that, had Baker 
 Brown lived, the history of this operation since 18G4 would have 
 been different. His own method of dealing with the pedicle by 
 the cautery at once lowered the mortality to one-half of that 
 with the clamp, and it was becoming practised in London when 
 illness came to him, and death. The man and his method were 
 quickly forgotten; no one would have the lesson his work gave. 
 All were strangely blind in those days to its value. Should I not 
 rather say, we were all strongly prejudiced ? In truth, there is 
 no more startling page in surgical history than that in which 
 his latest results are given. On one page w^e have almost noth- 
 ing but failures; on the other, by a simple change in the method 
 of operating, an almost uninterrupted line of success. During 
 the whole of his professional life he seems to have tried hard to 
 cure ovarian disease. From 1851 to 1864 he made many efforts 
 and tried many ways, all in vain, till he adopted the cautery. 
 His published results show a mortality of less than one in ten in 
 completed cases. I have read somewhere that he lost but four 
 of his last fifty operations. Some years afterward— unable to 
 get my mortality much under the one in five, for I was then ig- 
 norant of drainage — I took to Mr. Brown's method in a sort of 
 despair. For a time it was used irregularly, and only in the worst 
 cases, or in those not favorable for the clamp. The results of the 
 first fifty cautery cases, published in the Lancet, gave a mortality 
 of less than one in twelve — eight per cent., and the results that 
 followed were much better. Mr. AVells and Mr. Thornton have 
 lately given their statistics of cases performed under careful 
 antiseptic treatment, and with all the other improvements of 
 these later years, and the mortality is nearly eleven per cent. 
 
 " So much for Mr. Baker Brown's as compared with the other 
 methods. But, after all, what concerns us most now is, by whose 
 method may ovariotomy be performed with the least risk to the 
 patient ? Surely the one that gave us a death-rate of less than 
 eight per cent., long before antiseptics were heard of, is the 
 one to trust to now — such, at least, is my experience. The cautery 
 alone gave the best results of all the methods before. It gave bet- 
 ter results fifteen years ago than any other method can yet show 
 with antiseptics. Helped by drainage — for where would the an- 
 tiseptic system be without drainage ? — it gives the best of all re- 
 sults with them. Ninety-eight of my last hundred cautery opera- 
 tions have recovered, and in one of the two fatal cases the tumor 
 was malignant with cancerous matter in the pelvis, practically 
 an incomplete operation.
 
 248 DISEASES OP THE OVAKIES. 
 
 " Have I not reason, therefore, for saying tha,t, had Mr. Baker 
 Brown Hved, the history of ovariotomy since 1864 would have 
 been changed; and that, in making his calculations, Lord Sel- 
 bourne would have had to add three times the number of years 
 to the lives of women saved by ovariotomy ? " 
 
 In 1858 Mr. Spencer Wells began his work, and in his third 
 operation he adopted the clamp as a method of dealing with the 
 pedicle, and this he retained in all suitable cases until about 1878. 
 During this time he performed G27 operations with the clamp, 
 having a mortality of 20.73 per cent. During the same period 
 he operated 157 times with the ligature, with a mortality of 38.2 
 per cent., and on this point it is to be noted that he retained the 
 intraperitoneal method only for those cases to which he could not 
 a|jply the clamp. I mention this here merely to indicate my opin- 
 ion that the introduction of the clamp was a decidedly retro- 
 grade step in the history of ovariotomy. When I began my own 
 practice, in 1867, I employed the ecraseur, a variety of the in- 
 traperitoneal method, and my results over a limited experience 
 were extremely good. Like others, however, I was so impressed 
 with the overwhelming experience of Mr. Wells, that I resorted 
 to the clamp, and my results with it were so bad that its employ- 
 ment will ever be to me a matter for bitter and lasting regret. 
 
 In his lectures before the College of Surgeons Mr. Wells 
 gives the following account of his results : 
 
 ' ' With regard to the proportion of deaths to recoveries, tak- 
 ing my own cases only as a starting-point, of the 500 cases pub- 
 lished in my book, 373 recovered and 127 died — a mortality of 
 
 25.4 per cent of the 300 subsequent cases, published in 1873, in 
 the paper at the Royal Medical and Chirurgical Society, 223 re- 
 covered and 77 died — a mortality of 25.6 per cent. Since the 800 
 cases, I have now operated on exactly 100 more, making a total 
 of 900 complete operations. Of the last 100, 83 recovered and 17 
 died — a mortality of 17 per cent. Adding the whole 900 cases 
 together we have 679 recoveries and 221 deaths — a mortality of 
 
 34.5 per cent. It is satisfactory that in the last series of 100 
 cases the mortality is the least." 
 
 In the last hundred cases I believe some seventy-five or eighty 
 were dealt with by the ligature, and nothing could be more con- 
 demnatory of the clamp than such figures, which show that 
 after using it more than six hundred times in selected cases, 
 Mr. Wells could not bring his mortality below twenty per 
 cent., whereas, fourteen years before, Mr. Baker Brown had a 
 mortality of only ten per cent, with the intraperitoneal method. 
 
 In 18G2, Dr. Thomas Keith began his operations in Edinburgh, 
 and he speedily found, as he tells us, that the results obtained
 
 OVARIOTOMY. 249 
 
 by the clamp were extremely bad, and he reintroduced, and by 
 his brilliant work has completely re-established, the intraperito- 
 neal method of Baker Brown. With the clamp his mortality 
 was 19.2 per cent., which is close upon that of Mr. Wells, 20.73 ; 
 with the cautery, on the other hand, out of 156 cases Dr. Keith 
 has had a total mortality of only 3.85 per cent., and in addition 
 to this it can be shown by his constantly diminishing mortality 
 that with each series of operations his increased skill diminished 
 his death-rate, so that in his fifth series of fifty cases he had a 
 mortality of only eight per cent. No such progressive improve- 
 ment is seen in Mr. Wells' 627 cases of clamp treatment. 
 
 Just as this is written I have completed a series of a hundred 
 cases performed without any of Mr. Lister's so-called antiseptic 
 processes, and in all of which the pedicle was treated by the 
 "Staffordshire knot." Only two of these hundred cases have 
 proved fatal, and in both cases death was due to the fact that 
 they had been repeatedly tapped. 
 
 Dr. Keith {British Medical Journal, October 19, 1878) attrib- 
 utes his success to four conditions, of which he speaks as follows: 
 
 "'1. To drainage of the abdominal cavity in severe cases by a 
 large perforated glass tube going to the bottom of the pelvis. It 
 is to Koeberle that I am indebted for the idea. He kindly gave 
 me two of his small tubes in 1866. These were soon found to be 
 too narrow and too short. They got easily choked with clot or 
 lymph. For the last ten years, I have used the large glass tubes 
 now in common use. Till I had learned in what cases to drain, 
 the tube was used in alternate cases of the severe operations. I 
 am as certain as I am of my existence, that had I used them 
 earlier and oftener the mortality would have been less by one- 
 third. These tubes I supplied to ovariotomist friends in all 
 parts of the world, though no one used them, so far as I know, 
 till attention was called to drainage by the vagina by Dr. Marion 
 Sims — a method which seems to me to be one calculated rather 
 to give rise to blood-poisoning than to save the patient from it. 
 It is remarkable that the only year in which the mortality of the 
 Samaritan Hospital fell to 10 per cent, was in 1876, when drain- 
 age by these glass tubes was first generally used, 2. To the use 
 of the cautery in dividing the pedicle, as proposed and practised 
 by the late Mr. Baker Brown. How the lesson given by his last 
 results has been so systematically ignored in London has always 
 been a marvel to me. 3. To the employment of Koeberle's com- 
 pression forceps, in large numbers, whereby loss of blood is pre- 
 vented. His model is still the best, notwithstanding the clumsy 
 imitations of it lately invented. 4. To the substitution of ether 
 for chloroform in my last two hundred and thirty operations,
 
 250 DISEASES OF THE OVARIES. 
 
 whereby the after-vomiting is avoided, and the risk of hemor- 
 rhage when the wound is closed diminished. All these things 
 have, I think, helped to lessen the mortality, but the drainage 
 and the employment of the cautery in the division of the pedicle 
 have contributed most." 
 
 *• I wish, for the credit of my small hospital, which I carried 
 on almost entirely at my own expense, to make this statement 
 of results distinctly; and I would not make it prominent now, 
 but that year after year the authorities of the Samaritan Hospi- 
 tal proclaim in their reports, in the largest of Roman letters — 
 though one of the surgeons tells me that he has objected to the 
 statement in vain — that the results got there are always the best 
 that have yet been obtained, the mortality of the Samaritan 
 Hospital down to the end of 187G being nearly one death in every 
 four operated on; of the last five corresponding years, one in 
 five." 
 
 At this period the history of ovariotomy entered upon a new 
 phase by the introduction and application of what is called the 
 antiseptic theory and the Listerian method of putting this theory 
 in practice. Keith's results without this method were so bril- 
 liant as to put all other efforts in the shade, and, startled by them, 
 with one consent we followed in his footsteps. In my own prac- 
 tice the mortality fell from twenty-five per cent. , which seems to 
 be the normal rate following the use of the clamp, to seven or 
 eight per cent. , which seems about the rate possible when Baker 
 Brown's practice is followed. An attempt was made by Mr. Spen- 
 cer Wells and his assistant, Mr. Thornton, to cover their retreat 
 from the use of the clamp by claiming for the Listerian method 
 the merit of the reduced mortality: but in the proper place I shall 
 give reasons which have fully convinced me that it is to Mr. 
 Baker Brown and to Dr. Keith, but certainly not to Mr. Lister, 
 that we owe our recent and most brilliant results in this depart- 
 ment of surgery. 
 
 In the preface to Mr. Wells' first book on " Diseases of the 
 Ovaries," and again in his second edition in 1S7S, there is the fol- 
 lowing sentence. "Dr. Clay had steadily continued in the ca- 
 reer which he began in 1842, but his operations not being per- 
 formed in a hospital, before numerous professional Avitnesses, 
 and no connected series of his cases being published, his example 
 had but little influence." 
 
 These words are again used in an anonymous article upon the 
 history of ovariotomy in the British Medical Journal for July 
 17, 1880, and I think they give a very unfair representation of 
 the value of Dr. Clay's work. They convey the impression, 
 whether intended or not, that the writer considers Dr. Clay's
 
 OVARIOTOMT. 251 
 
 statements concerning his cases are not to be trusted, but for my 
 own part I am perfectly satisfied that there is not the slightest 
 reason for any such aspersion. It is quite true that Dr. Clay's 
 cases were performed in private practice, but if this is to be a 
 ground for suspicion of their authenticity, then at least half of 
 the contributions made to medical literature may be equally 
 doubted. We might just as well turn round and doubt the cases 
 which are credited to Dr. Ephraim McDowell; and the statement 
 made by Mr. Wells that Dr. Clay did not publish any " connected 
 series " is not correct, for he not only published a pamphlet, from 
 which I have quoted, and of which I possess a copy, but in 1857 
 he published a table in which he gave the results of fifty-one 
 operations. In his first twenty there was a mortality of forty 
 per cent. , in the second twenty about thirty per cent, mortality, 
 while in the last thirty-one operations it fell to twenty-five per 
 cent., and that mortality was maintained by Mr. Spencer Wells 
 for twenty years after the publication of what I am now quoting 
 from. Further, in Dr. Clay's publications and in the publica- 
 tions of others, it is made perfectly clear that he had performed 
 his operations before "•' numerous professional witnesses." 
 
 There can be no doubt, therefore, that Dr. Clay's example em- 
 boldened others to follow in his footsteps, and to him must be 
 given the first rank amongst English ovariotomists for the re- 
 vival and complete establishment of this most important opera- 
 tion. It must be borne in mind that, at the time in which Dr. 
 Clay practised, the exact method of recording cases, particularly 
 of ovariotomies, which now obtains, had not been introduced 
 in any department of practice, and even now it is almost con- 
 fined to abdominal surgery. No one seems to have published 
 any cases with the idea that at some later date a carping critic 
 might rise to assert that such a case had never existed. This is 
 a kind of argument which has received an almost universal 
 condemnation amongst honorable men, and it is one which can 
 only be made by insinuation, and its authors dare not give it by 
 direct statement. To Mr. Spencer Wells must be given the credit 
 of having introduced the exact statistical method, and this there 
 can be no doubt had a very large influence in consolidating both 
 professional and public opinion as to the propriety of performing 
 such operations; for it was not till then was there any possible 
 answer to such criticism as that directed against Dr. Clay. But 
 that Dr. Clay did not provide against that kind of criticism, 
 which he probably never expected, forms no justification for the 
 conclusion that his statements concerning his operations and 
 their results are not quite as correct as those of Mr. Wells or Dr. 
 Keith.
 
 252 DISEASES OF THE OVARIES. 
 
 What I have to say of the history of ovariotomy may be con- 
 cluded by an expression of opinion that the record of its progress 
 passes from Clay and Baker Brown to Keith, passing over alto- 
 gether the unfortunate interregnum of the clamp as something 
 deeply to be regretted. Not only by the re-establishment of the 
 intra-peritoneal method, but by the successful teaching of the 
 necessity for the complete cleansing of the peritoneum and the 
 occasional use of the drainage-tube, Keith has earned the lasting 
 gratitude of humanity. O 
 
 The treatment of ovarian tumors by therapeutics need not be 
 discussed, further than to say that it is limited to the adminis- 
 tration of tonics to sustain the functions of the patient, or to 
 correct some errant condition which might diminish the chances 
 of success for the surgical treatment of the case. Sometimes we 
 are the victims of singular coincidences, which seem to militate 
 against the general experience in this matter. Some years ago 
 I was consulted by a woman with an enormous unilocular tumor, 
 whose husband declined all operative measures. Some months 
 afterward she received from the hands of a physician some inert 
 placebo, and soon afterward the cyst ruptured and its contents 
 were absorbed. For nearly five years she remained perfectly 
 well and then the tumor reappeared. She was admitted into a 
 large general hospital, was operated upon and died in a few 
 days. The tumor proved to be, as I had anticipated, a parova- 
 rian cyst. 
 
 For the cure of an ovarian cystoma there is nothing known 
 to have the slightest influence save an operation for its removal, 
 and those patients who unfortunately are led to believe that some 
 drug or other, or some fanciful form of treatment will relieve 
 them from the necessity of an operative ordeal, are only induced 
 to waste time which is valuable, and to run risks which may be 
 avoided. On this subject Mr. Spencer Wells observes: '"But I 
 would also say that if the operation be delayed for a time, she 
 should not be subjected to any useless treatment: that it is quite 
 useless to attempt, by iodine, or bromine, or lime, or by gold, or 
 by any other remedy, to attempt to diminish the size of the 
 tumor or to check its growth. All that is quite useless, and 
 might be very injurious to the patient." 
 
 Sir James Y. Simpson expressed his experience in equally 
 strong terms when he said, ''he had no belief whatever that 
 iodine, or mercury, or muriate of lime, or aqua potassae, or 
 diuretics, or deobstruents, or aught else, were capable of absorb- 
 ing and removing the complicated structure and contents of a 
 multilocular cystic tumor of the ovary."' Mathews Duncan 
 Kays, " We know of no one example of the cure, otherwise than
 
 OVARIOTOMY. 253 
 
 by the operation of Ephraim McDowell, of an ovarian dropsy 
 properly so-called; not one, however many may be found de- 
 scribed, or whoever may be the describer. Cures by one or more 
 tappings, cures by medicines, cures by spontaneous rupture, 
 cures by advancing pregnancy, have been, if not mere egregious^ 
 mistakes, almost certainly cures of parovarian cysts whose his- 
 tory, as already known, quite accords with and explains such 
 erroneous allegations." 
 
 Of tapping I have said as much as I think necessary, but 
 here I may repeat what every one knows now, that it never cure& 
 a tumor, and that it onl}^ brings about complications. It is my 
 firm belief that if ovarian and parovarian tumors were never 
 tapped, but were removed early in their history, we should have 
 only a casual mortality from the operation of ovariotomy. Tap- 
 ping, therefore, in my practice, has become only a palliation for 
 tumors I could not remove. 
 
 Many other plans have been devised for the radical cure of 
 ovarian tumors, but they are now all abandoned in favor of ova- 
 riotomy ; and such methods of treatment as the injection of io- 
 dine or the establishment of fistulous tracks can only be justified 
 under very exceptional circumstances. 
 
 Before the reintroduction of the intra-peritoneal method by Dr. 
 Keith, we used to delay the removal of an ovarian tumor as long^ 
 as the patient could get about comfortably, and this was justified 
 by the fact that with the clamp we got only about seventy-five 
 per cent, of recoveries. But now that we can get ninety -five, and 
 when we might get ninety-nine per cent, of recoveries if there 
 were no delayed and tapped cases, my rule is to remove an ova- 
 rian tumor as soon as it is discovered, and this will soon come to 
 be the received practice. Tlie earlier the operation is performed 
 the more certain the patient is to recover, for the less likely are- 
 there to be any complications. However advanced a case may 
 be, I never refuse to operate, for I have seen some of the most un- 
 promising cases recover without interruption. Even when there 
 is strong reason to believe that the tumor may be complicated 
 with malignancy, I make an exploratory incision to remove all 
 doubt. In this way I find that my proportion of exploratory incis- 
 ions is increasing, for whereas formerly I made an exploratory 
 incision where I thought the tumor might be removed and where 
 I proved mistaken, I now make an opening often where I believe 
 the tumor cannot be removed, and here again, to my great de- 
 light, I am occasionally in error. An exploratory opening never 
 does any harm, and very often does a great deal of good, even 
 where the tumor cannot be removed, for I have repeatedly 
 known that after this operation there was no reaccumulation
 
 254 DISEASES OF THE OVAKIE3. 
 
 of ascitic fluid, where formerly it was abundant, and we some- 
 times see an exploratory incision arrest the progress of an irre- 
 movable tumor for a considerable time. I have now under my 
 care a patient with a large myxoma of the caecum whom an ex- 
 ploratory incision completely relieved from distressing symp- 
 toms for nearly two years. Sometimes, therefore, I now begin 
 an "exploratory incision" and end it as an "ovariotomy," 
 while formerly I used to start an " ovariotomy " only to end it as 
 an '• exploratory incision." There is only one risk to a beginner 
 in this, that he will have to learn when to stop at the mere ex- 
 ploration. To attempt the removal of a tumor and not be able 
 to finish it, is the most fatal of all proceedings, and therefore 
 the list of incomplete operations should always be a short one. 
 
 It is almost a matter of routine in the major operations of 
 surgery, that it should be carefully ascertained that the patient 
 is not suffering from organic or serious functional disease of any 
 important organ, and this, for ovariotomy, must never be neg- 
 lected. Especial care must be taken to examine the condition 
 of the urine, for the state both of kidneys and bladder is a most 
 important factor in the success of the operation. 
 
 I should not. however, hesitate to operate in a case where 
 there was even distinct indications of important visceral disease. 
 I have operated on two patients with marked disease of the 
 lungs, and they are both still alive and one has got nearly well. I 
 have operated in an advanced stage of Bright's disease, and the 
 patient recovered, was greatly relieved of her distress, and died 
 in the ordinary course of her kidney disease. Any visceral lesion 
 which can be remedied before the operation should of course 
 be put right, and this is most particularly true of the bladder. 
 If there is any chronic catarrh of that organ it should be cured 
 before the operation, for as the catheter has in many cases to be 
 used for some days, this condition will almost certainly prove 
 serious. 
 
 When an operation has been determined upon and every care 
 taken that any defect discovered has been rectified, we come to 
 discuss the stages of the operation, the precautions to be taken 
 before, and the treatment to be followed after it. First of all, 
 there is the position of the patient — where shall she be ? Expe- 
 rience answers that the more nearly her surroundings resemble 
 those in a healthy private house the better ; and the statistics 
 show that the performance of ovariotomies in a large general 
 hospital is altogether unjustifiable. There is no operation in the 
 whole range of surgery where the patient seems to be so apt to 
 be infected by septic influences, and no precautions against them 
 can be too great. For any surgeon to perform an ovariotomy
 
 OVARIOTOMY. 255 
 
 while he is engaged in dissection or in the performance of post- 
 mortem examinations, or while he is attending any case from 
 which he may be likely to convey septic infection, should there- 
 fore be looked upon as a professional offence of the gravest 
 kind. 
 
 Mr. Spencer Wells has always expressed his views very 
 strongly upon this subject, and they are well summed up in his 
 lectures at the College of Surgeons, ** Only two days ago," he 
 says, ''one of the most distinguished of the rising surgeons of 
 the day told me that he had gone straight from a post-mortem 
 examination to operate for strangulated hernia, quite confident 
 that the spray and washing the hands with carbolized water 
 would make him safe. This undue confidence in antiseptics 
 may lead to danger rather than safety, and so far I see no rea- 
 son for altering the opinion I expressed at Manchester last year, 
 that ' for my part I would rather operate in a clean, quiet, well- 
 warmed, and well-ventilated building, be it large or small, with- 
 out any antiseptic precautions, than run the risk of trusting to 
 the neutralizing or destructive power of chlorine or iodine, sul- 
 phur or tar, borax or the permanganates, salicylic or any other 
 acid, in a place tainted by the presence of sewer-gas, or the 
 seeds of some infectious or contagious disease.' " 
 
 As we have now had abundant opportunities of showing that 
 the so-called *' antiseptic system," even when carried out to its 
 full, gives no such absolute immunity from septic poison as is 
 claimed for it, this kind of teaching requires to be placed in 
 prominence, and therefore I add my own opinion, in a quotation 
 from a paper recently read before the Royal Medical and Chirur- 
 gical Society : 
 
 " Some of the warmest supporters of the antiseptic system 
 uphold it, on the ground that under its protecting influence oper- 
 ations can now be undertaken successfully which formerly were 
 impossible, such as laying open joints, etc. But I desire to point 
 out that this is an argument which cuts both ways, and which 
 seems to me to form one of the great dangers of antiseptic sur- 
 gery. The immense favor with which the antiseptic system has 
 been so widely received, is most undoubtedly due to the fulness 
 of its promise as a royal road to surgical success, as a something 
 which puts the skilled and the competent upon a level with the 
 inexperienced and incompetent ; and I know that there have 
 been abundant instances of bitter lessons already, that even an 
 antiseptic spray will not condone the want of manipulative dex- 
 terity or the absence of readiness in emergency, 
 
 '• There is, further, an inevitable result in the full acceptance 
 of this germ-theory adaptation, that the other factors — the con-
 
 25Q DISEASES OF THE OVARIES. 
 
 dition of the patient and his surroundings — will be relegated to 
 unimportant positions, and we shall have a great risk of inducing 
 an inattention to general hygiene and the incursion of rash expe- 
 riment, which will do more harm than antisepticism will do good, 
 even if everything claimed for it is true. That this is no fancy 
 sketch is proved by what Mr. Spencer Wells narrated in his lec- 
 tures at the College of Surgeons on abdominal surgery." 
 
 I can only say further that in my opinion any man who delib- 
 erately performs an operation under circumstances from which 
 his patient acquires fatal blood-poisoning ought to be the subject 
 of a criminal indictment. 
 
 I am also strongly of opinion that no surgeon engaged in con- 
 stant attendance on the promiscuous cases admitted to a general 
 hospital should perform such an operation as ovariotomy, and I 
 look on it as mere foolhardiness on the part of any one to per- 
 form it to whom it will probably never occur again to engage 
 with such a case, or whose experience is likely to be limited to 
 two or three such cases in a lifetime. It is an operation beyond 
 all others requiring that readiness of adaptation for emergencies 
 which wide experience alone can give. Its complications are far 
 more varied and tax far more heavily the courage and presence 
 of mind of the operator than those of any other operation in sur- 
 gery; and one or two successful cases scarcely compensate for 
 those which are unsuccessful by lack of experience. 
 
 It may be urged against these views that they are merely the 
 opinions of a specialist, and therefore represent only a limited in- 
 terest; but my experience, were I permitted to detail it, would 
 be sufficient not onl}" to convince my readers that my views are 
 well founded, but that they really represent the best interests 
 alike of the public and of the surgical profession. To any mem- 
 bers of my profession who may be inclined to argue this point 
 let me put the question as to whom they would entrust their 
 wives or sisters for the removal of an ovarian tumor — to a 
 surgeon engaged in general practice, whose experience of these 
 cases was limited to some half dozen cases with some two or 
 three deaths, or to one who engaged in this kind of work only 
 and diminished in every way all risks of infection, at the same 
 time that he increased his special experience ? The fact is, as 
 Simpson very well showed in 1845, it was to a large extent be- 
 cause the operation was not made a specialty that it was so 
 long in receiving professional acceptance. " The diagnosis and 
 the operation were, under the existing divisions and arrange- 
 ments of practice, undertaken by two different sets of practi- 
 tioners — the former by the obstetric physician, and the latter by 
 the operating surgeon. It was, perhaps, the only capital opera-
 
 OVARIOTOMY. 257 
 
 tion in which the surgeon was required to proceed upon tlie diag- 
 nostic knowledge of another party; and no one was to be blamed 
 if he felt a natural repugnance to incur so serious a responsibility 
 on such grounds." 
 
 It was mainly this which made Mr. Syme hold out so strenu- 
 ously against the operation and refuse, to the end of his life, to 
 perform it, even after Dr. Keith had shown what splendid results 
 could be obtained in Mr. Syme's own city. By common consent 
 it is being handed over to special practitioners, for whom no spe- 
 cial name has yet been coined, and whilst the department of ob- 
 stetrics is being retained by physicians, abdominal surgery is 
 passing over to the surgeons. 
 
 The room in which the operation is to be performed should be 
 fairly large, and so arranged that ventilation may be possible 
 from window or door to the fireplace without the current cross- 
 ing the bed of the patient. There should be no unnecessary fur- 
 niture, and as little upholstery work as possible. Two small 
 iron couches, with firm hair-mattresses and a water-pillow, are 
 needed; and an intelligent woman for nurse, who will do as she 
 is told, and nothing more, is absolutely essential. If two such 
 can be got to act as relays for the first eighty hours after the 
 operation, it will be found a great advantage. 
 
 For my hospital practice I have now arrangements altogether 
 different from those of my earlier experience, and the results are 
 correspondingly good. 
 
 The patient herself requires a little preparation for the 
 change that is about to be made in her alvine actions. For this 
 purpose, I direct that her food should be limited to soup and a 
 very little bread for forty-eight hours before the operation, and 
 that on the morning of the day previous she shall have a small 
 dose of castor-oil. The elaborate preparations which were in 
 vogue twenty years ago, of both the patient and her surround- 
 ings, are now quite abandoned. 
 
 I prefer that the room should have a northern light, that the 
 day should be clear, and I have the patient placed on a firm, nar- 
 row table with her feet directed against the window. The arms 
 and legs are secured by bands to the table, so that only one assist- 
 ant is required, one person to give the anaesthetic, and one nurse 
 to look after the sponges. All other bystanders are earnestly 
 requested to do nothing unless specially desired, and above all 
 not to speak during the operation. My assistant is duly in- 
 structed in his work, and I never, if I possibly can help it, operate 
 with any but my usual assistant, for it is quite as important 
 that he should know how to help me as it is that I should know 
 how to operate. All the preparations of the instruments and 
 
 17
 
 258 
 
 DISEASES OF THE OVARIES. 
 
 sponges I make myself, and then I am sure nothing is forgotten 
 — or if anything should be omitted, I have only myself to blame. 
 As a successful ovariotomy is the resultant of a large number 
 of petty details carefully attended to, no amount of care and 
 precision can be too great in carrying them out. 
 
 The instruments to be provided are, a perfectly sharp scalpel, 
 twelve of Koeberle's scissor-forceps, four handled needles 
 threaded with two thicknesses of silk, two pairs of cyst-forceps, 
 a pair of large screw bull-dog forceps, a wire clamp, a pair of 
 scissors, a number of pieces of fine silk, about a foot long, for 
 ligatures; a number of pieces somewhat thicker, eighteen inches 
 
 Fig. 30. — Tait's Modification of Koeberl6's Forceps. 
 
 long, for sutures; Paquelin's thermo-cautery, an aspirator, two 
 sizes of trocar, and twelve good sponges. Of this list some of 
 the items require special mention, and the first is the scissor- 
 forceps of M. Koeberle. Of the numerous minor improvements 
 in our method of operating, none deserves to be spoken more 
 highly of than the introduction of this instrument. I give above 
 a figure of the pattern (Fig. 30) I use, though I do not know that 
 it has much advantage over M. Koeberle's original form beyond 
 the fact that it is stronger and does not break, and that its pointed 
 nose cannot be tied in the ligature. Its method of action will 
 at once be seen. As soon as a bleeding point is seen it is seized
 
 OVARIOTOMY. 259 
 
 by one of these instruments and left in its clutches, so that when 
 the operation has advanced as far as the treatment of the pedicle 
 as many as eight or ten of these forceps may be hanging about 
 the wound. More than twelve are rarely required, and if there 
 should be need for more, one or two in use must be released by 
 the assistant throwing, a ligature round the points held by two 
 or three. I have never more nor less than twelve, and I have 
 them always ready to my hand in a small tray, covered with 
 water and ranged carefully in order side by side, so that at a 
 glance I can tell how many arein use. In this way I make sure 
 that I never leave one inside. 
 
 Mr. Spencer Wells gives a very graphic account of an acci- 
 dent of this kind from his own practice, which I quote in full to 
 show how easily it may occur in the most experienced hands and 
 how constantly an operator must be on the alert to prevent it : 
 " I took off, as I thought, every pair of forceps, closed the wound 
 up, and everything seemed quite as it should be. But about two 
 hours after the operation I received a message from a friend 
 who was putting up the instruments for me to say there was a 
 pair of forceps missing. We knew exactly the number of for- 
 ceps; if we had not known that, one pair would not have been 
 missed. This shows how necessary it is always to know how 
 many forceps are taken. It was about five in the afternoon when 
 I had this message: 'There is a pair of forceps missing; prob- 
 ably they may be in the patient.' Imagine the sort of feeling 
 with which one would receive that intimation. I at once went 
 to the patient. She seemed so well I did not like to disturb her; 
 there was some doubt where the forceps might be, so I thought 
 I would wait a little longer. I waited till night; she still seemed 
 pretty well, and I thought I would wait till the morning; but in 
 the morning the nurse told me the lady had been very restless. 
 I then made a careful examination by the vagina and rectum 
 and abdominal wall, to see if I could feel the forceps, but there 
 was nothing to be felt at all. Still I was uneasy, and I thought 
 I had better open the wound. So I asked Mr. Thornton to come 
 with me and throw some carbolic spray over the abdomen, and 
 making some excuse to the patient, just saying I thought it 
 necessary to change the dressing, and it would be as well that 
 she should not feel it, I gave her methylene, removed the dress- 
 ing, and took out two stitches. I put one finger in, but at first 
 could not feel the forceps. At last I found something hard, put 
 another finger in, and found the forceps wrapped up in the 
 omentum. From the way in which the omentum had insinuated 
 itself into the ring-handle of the forceps and between the blades, 
 it was easy to understand how difficult it was to find and re-
 
 260 DISEASES OF THE OVAEIES, 
 
 move the instrument ; but I did it, returned the omentum, closed 
 the wound, and the patient was none the worse. She got per- 
 fectly well, and to this day does not know that anything un- 
 usual occurred. Pray let me use this confession to impress upon 
 you the necessity, not only of counting sponges, but of counting 
 instruments also, that you may avoid any such painful experi- 
 ence." 
 
 These instruments are of great service in saving time, and 
 this is a matter of importance in an operation which may extend 
 over an hour. When the time comes for the removal of the for- 
 ceps, after the pedicle has been dealt with, it will generally be 
 found that the mere pressure has stopped most of the bleeding 
 points. These instruments will also be found of great service in 
 pulling out cysts and in many other ways which experience will 
 indicate. 
 
 The handled needles, armed with silk, are items of the list 
 upon which I take a great deal of trouble. They must be well 
 made and well tempered, so that they will neither break nor 
 bend. They must not have broad cutting points and must not 
 make big holes. The eyes must be perfectly smooth and round, 
 so as not to cut the silk. In fact, like everything else in ovari- 
 otomy, they must be perfection. The silk with which they are 
 armed is of two thicknesses, for I always tie a pedicle or a mass 
 of oinentum with the thinnest silk I think capable of securing it. 
 Therefore, for a thin pedicle I use thin silk, and for a thick pedi- 
 cle I use somewhat thicker silk. The silk must be pure Chinese 
 twist, with no cotton in it, an adulteration easily detached by 
 liquor potassse. I scald every piece of silk to be used before the 
 operation in boiling water, to get rid of the gum, and then I 
 stretch it tightly to test it and to reset its fibres. In this way I 
 have secured myself against ever having had a ligature slip, an 
 accident I have heard other surgeons complain of. 
 
 The form of trocar I use for emptying the cyst is figured on 
 opposite page, and I claim for it the advantages that, being per- 
 fectly solid, it never admits air, and having no inside mechanism, 
 it never gets out of order. The form of its point enables the 
 operator to puncture secondary cysts without any alteration of 
 the mechanism; it is not sharp and therefore can do no harm. 
 
 Of the sponges to be used it is almost impossible to speak with 
 too great emphasis, as I distrust them more than anything else 
 about the operation. I never let them out of my sight and I will 
 not permit any one but the nurse in charge of them to touch 
 them. They are prepared for each operation witlr the utmost 
 care and the number in use is constantly twelve. They are 
 counted before the operation, before the wound is closed, and
 
 OVARIOTOMY. 
 
 261 
 
 again afterward, so that by no possibility should one be left in- 
 side, an accident which has happened a great many times in the 
 history of ovariotomy and which nothing but the greatest care 
 will prevent recurring. Mr. Spencer Wells gives his experience 
 in this point as follows: 
 
 '' In one case I was a long time searching for a sponge before 
 I could find it. No one who has not tried would believe the diffi- 
 culty of finding a sponge in the abdominal cavity, if it be not 
 very large, and have become saturated with fiuid. The lady 
 was the wife of a surgeon, and I operated upon her in the fifth 
 month of pregnancy. After the pedicle was secured, and I was 
 closing the wound, the nurse said there was a sponge missing. 
 I said ' Are you quite sure ? ' She counted again, and said, ' I 
 am sure there is a sponge missing.' I felt in every direction in 
 this lady's abdomen; put my hand to the bottom of the pelvis, 
 to the front of the uterus, and everywhere I could think, but 
 
 Fig. .31. 
 
 find the sponge I could not. But at last, up to the back of the 
 liver, between the liver and the diaphragm, I found a small 
 sponge, and removed it. The patient made an excellent re- 
 covery, in spite of all this groping. But this leads me to repeat 
 the caution not to use sponges so small that they are not easily 
 found." 
 
 Let me further say again that no one should touch the 
 sponges but the nurse responsible for them. In one of my early 
 operations, many years ago, a bystander hearing me ask for a 
 small sponge tore one in two, so that there were thirteen in use 
 instead of twelve, and both the nurse and myself were ignorant 
 of the fact. The gentleman who tore the sponge alone knew of 
 his act, and he left the room before the operation was finished. 
 The result was that we found that thirteenth sponge four days 
 after, and the horror of the circumstance is as vividly in my 
 mind now as if it had happened yesterday. I shall never forget 
 it as long as I live. I happen to have heard of ten other cases
 
 262 DISEASES OF THE OVARIES. 
 
 in which sponges have been left behind, so that I need no excuse 
 for the emphasis of my advice on this point. 
 
 The sponges used should be of the very best quality, should 
 vary somewhat in size and shape, and should be perfectly free 
 from tears or ragged points, from which pieces may become de- 
 tached. When they are new I soak them for twenty-four hours 
 in a solution of muriatic acid sufficiently strong to be disagree- 
 ably sour to the taste. This dissolves the particles of chalk with 
 which they are infested and loosens the sand, and this must be 
 completely washed out of them. After each operation I wash 
 thein free from color and then soak them for forty-eight hours 
 in a strong solution of washing-soda or ammonia, to dissolve the 
 fibrin. They are then washed repeatedly until the water comes 
 from them perfectly clean, and after that they are placed for a week 
 in a five per cent, solution of phenol. Finally, they are hung up 
 in a well-made calico bag in a warm place till they are quite 
 dry. I keep a very large stock of sponges, and they are a con- 
 stant source of anxiety and care. It is to Dr. Keith that we are 
 indebted for the free and efficient sponging out of the abdomen 
 now always practised, and in this respect he has again largely 
 contributed to the advanced success of abdominal surgery. 
 
 It hardly requires to be said that the selection of an anaes- 
 thetic is an important matter for the success of ovariotomy. By 
 common consent the agent which for so many years held a su- 
 preme position in this country has given way to that which was 
 first introduced for the purpose of procuring unconsciousness to 
 pain in surgical operations. Chloroform, while it acts with an 
 almost mathematical certainty upon a woman in labor, is a most 
 unsafe and uncertain drug to use in surgical operations, save in 
 the case of a very young child. It is not only that we have a 
 considerable number of deaths from chloroform, but that in its 
 use we have so much anxiety that the danger is ever present in 
 the mind of the operator, and this distraction is destructive of 
 that clear concentration which is necessary in the performance 
 of ovariotomy. 
 
 Mr, Spencer Wells has for a long time advocated the use of 
 the bichloride of methylene by means of Junker's apparatus, and 
 this is certainly a very elegant, rapid, and, compared with chloro- 
 form, safe means of inducing ansesthesia. There are, however, 
 two objections against its use; one is that it requires a special 
 apparatus, and the other that this apparatus requires some one 
 experienced in its use. In the hands of one who is accustomed 
 to give the bichloride I think it is probably as safe as any anaes- 
 thetic well can be, but as it is wholly impossible always to obtain 
 the services of one sufficiently skilled, I have for a long time dis-
 
 OVARIOTOMY. 263 
 
 continued the use of this agent. There are other reasons against 
 its use which I do not think of sufficient importance to dwell 
 upon. The agent I have employed for the last six years is free 
 from any objection of an important character. I allude, of course, 
 to sulphuric ether, which is now recognized as by far the safest 
 anaesthetic in use, the kind of ether which I employ and which 
 I prefer above all others being the anhydrous methylated ether 
 manufactured by MacFarlane & Co. , of Edinburgh, as originally 
 recommended by Dr. Keith. The advantages of this agent are 
 very numerous. In the first place, so far as its present use has 
 gone, it is absolutely safe; in my own practice it has been used, 
 on a rough estimate, between five and six thousand times, and 
 not only have I had no accident from it, but its use gives me no 
 anxiety whatever, and whilst I am engaged in operating my 
 mind is absolutely at rest concerning the anaesthetic.' In the 
 next place, it may be administered by any one, and when I say 
 that in the whole of my hospital practice, for nearly three years, 
 the ether has been administered for all operations by the sister 
 in charge or by a nurse, I think I give testimony sufficient as to 
 my confidence in the safety of the drug. 
 
 For its proper administration very few rules need be observed 
 and no kind of special apparatus is needed. It is always given 
 for me after the simple fashion which Sir James Simpson intro- 
 duced for the administration of chloroform, that is by dropping 
 it on the outside of a single fold of a towel, laid upon the pa- 
 tient's face. Bearing in mind that ether is extremely volatile, 
 and that its vapor is very heavy, the following directions must 
 be attended to. The towel used must not be too thin, because it 
 must retain a sufficient body of ether for the continuance of the 
 current of vapor; and yet it must not be so thick as to prevent 
 the passage of air freely through it. The ether must be dropped 
 on to the towel, not splashed on, but administered in a continu- 
 ous stream, which must be allowed to drop from a small orifice 
 on to the towel, above the level of the patient's nose, because the 
 vapor of the ether will fall like a cataract over the patient's face. 
 If the ether is dropped on the towel on a level with the patient's 
 mouth, she will inhale, not the vapor, but a mixture of air and 
 ether, which will act as a stimulant and not as an anaesthetic, and 
 the ether must not be splashed on, for exactly the same reason. 
 The towel should not be tightened over the face, but puffed out 
 around it at a distance of an inch, or an inch and a half, from 
 the skin, in order that it may enclose a body of vapor. The 
 
 ' Since writing this I have had an accident (British Medical Journal, July 14, 
 1882) due, as I think, to the use of an inhaler.
 
 264 DISEASES OF THE OVARIES. 
 
 whole of the piece of towel covering the face must be kept con- 
 tinually moist with ether, and in this way a continuous volume 
 of pure ether vapor will be inhaled by the patient. After a few 
 minutes the part of the towel in use must be changed for another 
 part, because anhydrous ether absorbs with intense avidity the 
 moisture of the breath, and the towel will be found coated with 
 ice, and this, by its interference with rapid evaporation, prolongs 
 the process : this is the chief argument against all ether inhalers. 
 Only one other caution need be given, and that is to avoid bring- 
 ing any light or red-hot cautery near the patient's face while the 
 ether is being given, for it is explosive. 
 
 When these rules are attended to, ether will be found to be 
 the safest, quickest, and most satisfactory of all anaesthetic 
 agents. It has only three objections, and these are of but slight 
 importance. The first objection is that the smell of the ether 
 hangs about the clothes of those engaged in the operation, and 
 this is offensive to many persons; the second is that the quan- 
 tity of ether used is much larger than that of any other anses- 
 thetic and therefore it is necessary to keep it in large bulk; and 
 the third objection is that the taste of the ether is by no means 
 so pleasant as either chloroform or methylene; but upon this 
 point I have heard considerable difference of opinion. The cost 
 of the ether is less than that of any other anaesthetic which I 
 have used. 
 
 During the administration of ether there should be absolute 
 silence in the room. No one should be allowed to talk; more 
 particularly, no allusion should be made to the patient, or to the 
 prospects of the operation, because for a long time after insensi- 
 bility has apparently been reached ideas may be picked up by 
 the patient from suggestions made at the bedside, and these 
 often have a lasting and most disagreeable effect. This was 
 one of Simpson's most stringent rules, and one which never 
 ought to be broken. At the beginning of the process the quan- 
 tity of ether should be small, in order to avoid giving the patient 
 the sensation of being suffocated, because it is at this stage that 
 the state of mind is induced which leads to struggling. Nothing 
 makes any one struggle more than the sense of being choked. 
 As soon as it is evident from the regularity of breathing that 
 the patient has become accustomed to the presence of the ether 
 vapor in the air the quantity given may be increased to that 
 which has been already indicated, and if this condition be at- 
 tended to it will be found that struggling will be altogether 
 avoided, save in the case of children. When the patient does 
 struggle, the only thing to be avoided is her getting hold of the 
 towel, and it will generally be quite enough for the nurse or as-
 
 OVARIOTOMY. 265 
 
 sistant to keep the hands quiet while the administrator of the 
 ether steadies the head. Whoever gives the ether should ahso- 
 lutely mind his or her own business, and take no interest what- 
 ever in the surroundings during the whole of the process; for 
 even with an anaesthetic so safe as ether it is absolutely neces- 
 sary that the whole attention should be engrossed with it. 
 
 Sickness is with ether, as with every other anaesthetic, a 
 somewhat frequent trouble, and indeed it is difficult to see how 
 it can be altogether avoided. It is very rare, however, that it 
 need be a source of anxiety; but in one instance in my practice it 
 was extremely serious, and the story of the case will give a les- 
 son more emphatic, perhaps, than any mere directions which I 
 can give. 
 
 A lady was placed under my care some three years ago for 
 the purpose of having an ovarian tumor removed. She was, as 
 usual, kept in bed for two or three days before the operation and 
 on the morning of the operation nothing was given to her by her 
 attendants, in order that sickness might be avoided. The opera- 
 tion was to be performed at nine o'clock, and she, being pro- 
 foundly persuaded that upon an empty stomach she never could 
 go through the ordeal, rose about six o'clock on the same morn- 
 ing, went to one of her boxes, which had been unfortunately left 
 in her room, and in which she had secreted a quantity of bis- 
 cuits and a bottle of port wine, and with these she made a hearty 
 meal. In the middle of the operation sickness came on and she 
 vomited a large quantity of purple pulp. She went on inces- 
 santly vomiting for eight days, and long before that time I had 
 given up all hopes of her recovery. The straining caused by the 
 retching tore the wound open, and upon the sixth or seventh day 
 a large sloughy mass was extruded, which proved to be the rec- 
 tus muscle of the left side, which had apparently been destroyed 
 by the continuous vomiting. For ten days more she lay with a 
 large, open wound, through which could be seen the movements 
 of the intestines, and between her and another world, there was 
 nothing but a layer of peritoneum. Fortunately, she did not 
 open the wound any farther. She ultimately recovered, and is 
 now'in perfect health, save that there is a large intestinal protru- 
 sion at the seat of the wound. I do not think that in the whole 
 course of my practice I have ever had a case which gave me so 
 much anxiety, and it also gave me a powerful argument by 
 which to impress upon others the absolute necessity of obedi- 
 ence. 
 
 The anaesthetic should, therefore, be always given upon an ab- 
 solutely empty stomach. I do not even approve of the dose of 
 brandy and water usually given, because ether is in itself one of
 
 266 DISEASES OF THE OVAEIES. 
 
 the most powerful stimulants, and we have only to watch the im- 
 provement upon a feeble pulse which takes place during its ad- 
 ministration to be quite satisfied that no other stimulant is neces- 
 sary. The quantity of ether given during an operation, especially 
 during ovariotomy, is necessarily very large, but no one need ever 
 be alarmed on account of the quantity of ether administered. It 
 is absolutely necessary to keep all the patient's abdominal mus- 
 cles, except the diaphragm, perfectly quiet; and long before 
 there is the least danger the patient's deep snoring will indicate 
 that the stage of profound sleep has been reached. When the 
 patient snores the administration should for a short time be dis- 
 continued. The quiet regularity of breathing which always 
 characterizes the unconscious state induced by breathing the 
 vapor of ether is quite enough to indicate to any one of any ex- 
 perience in its use that the patient is in a condition of profound 
 insensibility, and this will also serve as the best indication of 
 safety. There is, therefore, very little need for the pulse being 
 watched, or for the conjunctiva to be experimented upon to de- 
 termine unconsciousness. Should sickness come on during the 
 operation, the ether should be pushed a little more and this will 
 stop it, because sickness really is an indication of returning con- 
 sciousness. After the operation is over, should sickness occur, it 
 is best checked by the administration of a little luke-warm water 
 flavored with brandy, and without sugar. "When the patient is 
 sick she should always be turned on her side, as in this position 
 the tongue falls forward and the vomit is got easily rid of from 
 the mouth without risk of its entering the trachea. Forceps 
 should never be used to drag the tongue forward, after the bar- 
 barous fashion introduced by the late Mr. Syme. It is quite suf- 
 ficient to turn the patient on her side, or even to turn the head 
 to one side, if any necessity arises for this during the operation. 
 Artificial teeth should always be removed from the mouth before 
 the ether is given. 
 
 There is only one risk about the administration of ether, and 
 that is the occurrence of bronchitis in old people. I have not 
 seen this often, but in several instances I have had reason for 
 anxiety on this ground, and in order to avoid this risk I have 
 devised an apparatus by which the vapor of ether is given at a 
 temperature of 33° Centigrade, that is, very nearly its boiling- 
 point. 
 
 The woodcut on opposite page will explain the apparatus 
 which I have devised for the purpose. Anhydrous methylated 
 ether (.720) is placed in the reservoir. A, which will hold about ten 
 ounces, and which is furnished with a spring pump, which drives 
 over about a dram of ether at each stroke into the glass boiler, B.
 
 OVARIOTOMY. 
 
 267 
 
 This boiler is suspended in a hot-water tank, C, beneath which 
 is a spirit-lamp. From the boiler an exit tube, four or five feet 
 long, passes to a Junker's mouth-piece. 
 
 When the apparatus is to be used, the tank is filled with 
 water, the spirit-lamp is lighted, and about three drams of ether 
 is pumped into the boiler. Care must be taken that there is no 
 leakage from the boiler, otherwise there will be an ignition. It 
 will soon be found that the boiling ether gives over a large vol- 
 ume of vapor at a constant temperature of a few degrees below 
 the boiling-point of the sample, which of course will vary very 
 much, but will generally be found to be pretty nearly the tem- 
 perature of expired air, 31°— 33° Cels. When given at this tern- 
 
 Fig. 32. — Apparatus for the Administration of Etlier-vapor at Blood-lieat in Cases of Old People. 
 
 perature, and free from air, the vapor is quite pleasant, and its 
 taste or rather its comparative freedom from taste, reminded me 
 when I tried it on myself, greatly of the flavor of nitrous oxide. 
 It is, of course, certain that its administration will involve no 
 risk of bronchitis. 
 
 I think this method will be found to be a substantial advance 
 in the method of ether administration for old people; and if care 
 be taken to keep the boiler vapor-tight, and the mouth-piece 
 three or four feet away from the spirit flame, I think the appara- 
 tus will be found quite safe. Dr. Lauder Brunton made to me 
 the ingenious suggestion of having a steam-jacket round the 
 boiler, but that I have notfound to be practicable without greatly
 
 268 DISEASES OF THE OVARIES. 
 
 complicating the apparatus. The use of a hot iron bolt to boil the 
 water, instead of the lamp, would probably be safer, but it would 
 not be so handy, and would involve great wear and tear. 
 ^ There comes in now the question of the adoption of what are 
 called antiseptic precautions, and of these it is quite impossible 
 to speak without a discussion, however brief, of the theory upon 
 which they are based. This is necessary for many reasons, but 
 chiefly because the followers of the antiseptic doctrine assert, 
 with a vehemence worthy of the scholastics of the fifteenth cen- 
 tury, that unless there be faith in the doctrine there can be no 
 success in the practice. 
 
 To those who have followed closely the elaborate researches 
 upon the phenomena of putrefaction, which have occupied some 
 of the greatest minds of our time during the last fifteen years, it 
 must, I think, be admitted as an established fact that these 
 phenomena arise from the presence of minute living organisms 
 in the air, which can be removed from it by a variety of physical 
 means, by which the air is rendered absolutely harmless to the 
 substances which are experimented upon. Further, that so far 
 as we know, no phenomena of putrefaction do occur without the 
 admission of these so-called germs to the substance putrefying, 
 that the putrefactive processes depend entirely upon them and 
 the organisms to which they give rise, and that the origin of 
 such organisms within the putrefying fluid, independently of a 
 sowing of seed in the fluid, though by no means to be regarded 
 as an impossibility, is not yet proved as an actual occurrence. 
 To any who takes a general view of tlxe biological scheme from 
 the aspect of the evolutionary philosophy I think it must be 
 clear that the so-called ' ' spontaneous '' generation of the early 
 forms of life is a necessary corollary, but it is by no means cer- 
 tain that it is a part of the present process, nor is it likely, in my 
 opinion, that we now have upon the earth such conditions as 
 would render biogenesis possible. 
 
 For my present purpose, therefore, it is enough for me to as- 
 sume, as I do most fully, that the germ theory has been com- 
 pletely substantiated, and that no known process of putrefaction 
 does occur save by the admission of resting spores or swarm 
 spores of some of the many minute living organisms which are 
 invariably associated with putrefactive changes. But concern- 
 ing this there is another constant position associated with these 
 phenomena. The materials upon which the experiments have 
 been made, of infinite variety of kind and constitution, have all 
 been dead, and no one has yet pretended that, by the admission 
 of germs to living matter, he has produced the phenomena of the 
 putrefactive changes which constantly result in matter which is
 
 OVAKIOTOMT. 26JI 
 
 dead. To quote the apt illustration given by Dr. Wm. Roberts 
 in his masterly exposition of this most difficult subject, the ordi- 
 nary hypodermic morphia syringe will inoculate inevitably a 
 sterilized solution of dead organic matter, but amongst the hun- 
 dreds and thousands of hypodermic injections which are made 
 daily, no one has yet declared a single instance of putrefactive 
 changes resulting from it in the healthy, or even in the diseased 
 human body. . 
 
 It will, therefore, be seen that the application of the facts of 
 the germ theory of putrefaction to the phenomena of diseases of 
 living tissue is met at once by an overwhelming difficulty, to the 
 removal of which none of the adapters, so far as I have seen, 
 have as yet applied themselves. Granting that the same germs 
 which would inevitably produce putrefaction in a dead infusion 
 of beef are constantly admitted to wounds, there is not the 
 slightest particle of evidence that they do produce any change 
 whatever upon living tissue, still less is there any evidence that 
 the changes which occur in the numerous varieties of what we 
 call blood-poisonings, even when they are of an undoubtedly 
 local origin, have the slightest analogy to those seen in a putre- 
 fying dead infusion. The mere presence of bacteria in the fluids 
 of wounds, or in fluids enclosed in cavities, whilst offering many 
 difficulties to the adapters of the germ theory, prove nothing for 
 their 'position until they have shown that these organisms ever 
 do occur in fluids or tissues which are truly living. 
 
 The difficulty, therefore, is this, that what we call vital action, 
 for want of a name based upon a better understanding of what 
 it is, places living tissue in an altogether different category from 
 tissue in which the phenomena of life are no longer present. 
 
 Now, this is consonant with e very-day experience. If a de- 
 caying hyacinth bulb or a rotting apple be examined, the pre- 
 sence of the minute forms of life is found to be absolutely con- 
 fined to those parts where the changes have been effected, whilst 
 those parts to which the rot has not extended are found abso- 
 lutely free from them, and the difficulty of the adaptation of the 
 germ theory is simply this, that its advocates have assumed that 
 the invasion of the germs is the cause of the decadence of the 
 vital phenomena and the ultiinate death, while there is the al- 
 ternative — still undiscussed and certainly undismissed — that the 
 decadence of the vital powers, due to some cause possibly yet 
 unknown, is that which gives the germs their potential ascend- 
 ancy, and enables them to do what, during full vital action, they 
 were wholly unable to effect. 
 
 If the views of the germ theorists were correct, we ought to 
 expect that no operation could be done successfully without rigid
 
 270 DISEASES OF THE OVARIES. 
 
 antiseptic precautions. The slightest cut of the skin ought to 
 be followed by septic poisoning. There ought to be no differ- 
 ence in the mortality of operations in small and in large hospi- 
 tals, in town and in country. In fact, if germs could have had 
 the unbounded influence which is claimed for them by many an- 
 tisepticists, surgery must long ago have been an extinct art, if, 
 indeed, it ever could have struggled into existence. 
 
 The uniform experience of operating surgeons has taught 
 them that the success of their work will depend upon three fac- 
 tors, the condition of the patient, the condition of his surround- 
 ings, and the nature and extent of the operation performed. 
 
 Of these three, undoubtedly the most uncertain factor is the 
 first. What condition of the system it is which is favorable 
 to operations is almost unknown. I must base my conclusions 
 chiefly upon my own work, and in my special operation of 
 ovariotomy I am perfectly certain that apparent perfect health 
 is by no means a certain indication of a power of resistance to 
 those conditions, whatever they be, which result in so-called 
 septic poisoning. 
 
 The second of the factors, the condition of the surroundings 
 of the patient, contains elements of far greater certainty. It 
 has approached the position of a statistical law that the death- 
 rate is in constant harmony with the density of the population, 
 and that v/hen the density exceeds a certain minimum of safety 
 there are introduced specific septic diseases, as typhus fever, 
 which are wholly unknown under other conditions, and which, 
 even after the danger density has been reached, attack certain 
 individuals only, and not all, for reasons which can be expressed 
 only by saying, as I have already said, that the living tissues of 
 those affected could not, and did not, resist the septic influence. 
 
 Every advance we make in sanitation shows that this factor, 
 the condition of the surroundings of the patient, is of extreme 
 importance. 
 
 The third factor which influences surgical success is the ex- 
 tent and importance of the operation performed. Everybody 
 knows that while amputation of a finger is probably fatal in not 
 more than one in ten thousand cases, nearly one-half of all am- 
 putations of the thigh die. Now, if the adaptation of the germ 
 theory to surgical practice were as promising and as legitimate as 
 some of its supporters allege, we should have had the remarkable 
 result, previous to its application, that amputations of the fin- 
 ger and of the thigh ought to have approached one another in 
 mortality to an infinitely larger extent than they have done. 
 
 If the contact of a bacterium germ upon a wound could be 
 the source of blood-poisoning, then the size of the wound and
 
 OVARIOTOMY. 271 
 
 the nature of the operation could make but small difference in 
 the result, and a wound into the theca of a finger tendon, and 
 one of similar size into the peritoneum of another patient in 
 the same ward, ought to have very similar risks. But, as a 
 matter of fact, they do not, and we are forced to the conclusion 
 that, even if bacterium germs lighting on wounds are the 
 cause of much surgical mortality, that the power of vital resist- 
 ance by the tissues, or the condition of the patient, and the ex- 
 tent and nature of the operation, are of infinitely greater impor- 
 tance as factors in the general result. This logical difficulty has 
 evidently occurred to many of those who carry out Mr. Lister's 
 adaptation of the germ theory to surgical practice. I have seen 
 a rigid antisepticist occupy an hour and twenty minutes in mak- 
 ing incisions a fraction of an inch in measurement, and barely 
 skin deep, for the purpose of laying bare the tympanic mem- 
 branes of an infant in whom they had been congenitally cov- 
 ered, the protraction of the operation being due solely to the 
 antiseptic precautions. Such a proceeding produced in my mind 
 a variety of emotions, chief of which were admiration for the 
 enthusiastic consistency of the operator and sympathy for his 
 evidently wearied audience. The just criticism of such a pro- 
 ceeding is the question, •' Has any one ever seen such a trivial 
 operation result fatally from septic poisoning, unless in some 
 such hospital, as is described by John Howard in 1780, as the 
 Hotel Dieu, with three patients in each bed ? " I certainly 
 never have, and I have performed some thousands of them ; and 
 if it were necessary to take one hundred minutes to do what I 
 could do in three I, for one, should seek my livelihood in some 
 employment other than that of an operating surgeon. 
 
 The logical conclusion to be drawn from the facts is, therefore, 
 that in minor operations germs have never, or at least hardly 
 ever, any influence at all, and that in major operations the con- 
 dition of the patient is of immense importance in enabling him 
 to resist the influences, whatever they may be, which result in 
 what we call the septic condition. 
 
 In any examination of the question there will of course be the 
 primary difficulty, that it is by no means agreed as to what con- 
 stitutes a major operation, and that between different operations 
 which are admitted as major, there are known to be very different 
 rates of mortality. Thus, amputation of the leg is proved, in 
 my book on " Hospital Mortality," to be more than twice as fatal 
 when performed for accident as when performed for disease. It 
 must be perfectly evident, therefore, that any examination of 
 this question must be conducted upon the usual rules of statistical 
 investigation, the chief of which is that similar and not dis-
 
 272 DISEASES OF THE OYAKIES, 
 
 similar accidents should be grouped together. Any mere state- 
 ment, therefore, of the general percentage of deaths from septic 
 diseases on the general hospital or other population are abso- 
 lutely worthless unless they be most carefully analyzed, and they 
 are, of course, open to the still further objection that what con- 
 stitutes a death from septic disease is by no means a perfectly 
 accepted definition. 
 
 There is a popular belief that statistics can be made to prove 
 anything, than which there is no popular belief more erroneous. 
 Statistics alone seldom prove anything, certainly they never ex- 
 plain anything. Thus, the Registrar-General's tables tell us 
 that there are certain death quantities which are perfectly con- 
 stant, and they establish the fact that half of all our human 
 mortality occurs before the fifth year of life. But this neither 
 proves nor explains the cause of this mortality, nor does it even 
 explain its factors, until a more careful analysis of individual 
 cases is made. Therefore, nothing whatever can be proved for 
 or against the adaptation of the germ theory to surgical practice 
 by mere statistical statements. But in spite of this, statistics 
 may be made to show exactly in what direction analysis of indi- 
 vidual instances should be made, and, therefore, they alone are 
 capable of forming the first step of accurate inquiry. First, let 
 us ascertain, as fully as possible, what the facts are, and then 
 analytical arrangements of them will certainly afford a more or 
 less complete explanation of their method of production. 
 
 Thus, it must be evident to every one that a large group of 
 one hundred ovariotomies must present features more similar to 
 those of another set of a hundred than can probably be got in 
 any other surgical comparison which is possible ; and it is a 
 probably correct assumption that if the same surgical skill and 
 patience, the same attention to minute details, and the same 
 state of the surroundings were common to the two groups, their 
 resulting mortality would be identical or nearly so. But if there 
 is one thing we value more than another, as being likely to con- 
 tribute to success in surgical operations, it is personal experi- 
 ence ; and we, therefore, may fairly expect that with each suc- 
 ceeding hundred ovariotomies the mortality will diminish, owing 
 to the increasing skill of the operator. And this is the case not- 
 ably in the practice of Dr. Keith, who, beginning with eleven 
 per cent. , went successively down to eight and six before he be- 
 gan to use antiseptics ; and of my own experience I can only say 
 that, while I had nineteen deaths in my first fifty operations, I 
 had only three in my second fifty, and in all my subsequent 
 practice these good results have been fully maintained ; indeed,, 
 have been excelled.
 
 OVAEIOTOMY. 271^ 
 
 A recovery after an ovariotomy is the sum of a number of 
 details, all of which were efficient. A death, on the contrary, 
 may be the failure of one only, and that may be or may not be 
 under the control of the surgeon. Thus, of the three fatal cases 
 in my second fifty, two were deaths due to details wholly beyond 
 my control, and having no relation whatever to either the anti- 
 septic system or any other of the operative details. The third 
 death was due, as far as I could determine, to the irritative effects 
 of thymol, used with full antiseptic details. Two of these deaths 
 were antiseptic out of twenty-nine cases treated antiseptically ; 
 while of twenty-one cases treated without antiseptic precau- 
 tions, I had only one death, and as the patient died within three 
 hours after the operation, the want of antiseptic precautions 
 could have had nothing to do with her death. From this group of 
 cases, therefore, the argument would be wholly against the anti- 
 septic system, and though my impression is that the conclusion 
 would be a just one, yet the argument is absolutely fallacious, 
 as all such are. 
 
 In the discussion of this question, which occurred some 
 months ago, the only statistical argument of the slightest impor- 
 tance was given by Mr. Spencer Wells, who said that a very 
 marked improvement had occurred in his results since he had 
 used antiseptic precautions. But nearly concurrently with his 
 adoption of germicides, he adopted the intra-peritoneal method 
 of dealing with the pedicle, a method which has beeri^'superla- 
 tively successful in the hands of Dr. Keith, and to which, chiefly, 
 I attribute my own rapidly increasing success. Thus, Mr. Wells' 
 mortality improvement argues nothing in favor of antiseptics,, 
 but far more, in my opinion, for the short ligature. 
 
 The greater part of what I have just said upon this most inter- 
 esting and important subject, is taken from a paper which I read 
 before the Royal Medical and Chirurgical Society of London, in 
 February, 1880, and which is published in vol. Ixiii. of the " Trans- 
 actions," and its general conclusions are quite in harmony with 
 the opinion expressed by Mr, Spencer Wells, in his lectures de- 
 livered before the Royal College of Surgeons. I give his opinions 
 as they are reported in the medical journals at length, for they 
 are very important. He says: '"If (say the supporters of Lis- 
 terism) in one of the most serious operations ever performed 
 upon the human body, where the largest serous cavity is opened 
 and the freest access is afforded to any infective organisms 
 which may be near the patient, Mr. Wells can obtain eighty re- 
 coveries out of one hundred operations ; and as on two occasions 
 he has had long series of successful cases — one of twenty and two 
 of twenty-seven — without a death to break the run of success : 
 18
 
 274 DISEASES OF THE OVARlfiS. 
 
 if in the last two years of his practice at the Samaritan Hospital, 
 in 187G and 1877, he had only seven deaths out of seventy-one 
 cases — not one in ten — and all this without any of the special pre- 
 cautions supposed to be necessary by the advocates of the antisep- 
 tic system — never using the spray nor any carbolized solutions for 
 sponges or instruments, no catgut sutures, and no protective car- 
 bolized gauze for dressing ; if such results as these, in such an 
 operation, have been obtained, is it possible that the germ theory 
 can be true or the practice founded upon it necessary? It is 
 troublesome ; may it not be injurious ? Cases of poisoning by 
 carbolic acid — fatal poisoning — have been recorded, and, in many 
 cases where recovery has followed, the patients have been ex- 
 posed to great suffering and inconvenience. " > *_ 
 
 "They claim the successes as proofs of the value of the [anti- 
 septic] system ; they explain the failures by some alleged neglect 
 of some petty detail. In one case I thoughtlessly used a clamp 
 which had not been carbolized, and was warned of probable fail- 
 ure ; but the case appears, in spite of my negligence, on the list 
 of successful antiseptic operations, and was one of the cases in 
 which there was no fever after the operation. If there had been 
 any fever, no doubt it would have been explained to the entire 
 satisfaction of many people by the presence of some infective 
 germs on the clamp. Of course, this explanation might possibly 
 be true ; and I freely admit that, in an experimental inquiry, no 
 such carelessness should be permitted, especially as it gives rise 
 to the suggestion, from zealous or enthusiastic partisans, that no 
 one but themselves can be safely trusted to perform an operation 
 antiseptically. '' If," they say, ''you do not believe in the pres- 
 ence and omnipotence of germs — infective germs — all about the 
 patient and surgeon, nurses, bedding, instruments, sponges, 
 dressings— indeed, always and everywhere — you will be sure to 
 leave some loophole unprotected against the entrance of one or 
 more of these dreaded enemies. You must accept the theory, or 
 act as if you did, or your practice will certainly be faulty." My 
 answer to this would be that I have watched the performance of 
 a good many operations by surgeons who have complete faith in 
 the system, and who believe they carry it out accurately, but I 
 have never yet seen one case where a good many germs might 
 not have escaped the action of the carbolic acid ; and I believe 
 that I or any surgeon present who wishes conscientiously to 
 protect his patient from any of the atmospheric or other im- 
 purities which may possibly affect her injuriously, whether 
 he uses carbolic acid or any other antiseptic, may, by careful 
 attention, do so as completely and thoroughly as the most ac- 
 <"nrate experimenter can desire. Feeling all this, and feeling,
 
 OVARIOTOMY. 275 
 
 also, that undue faith in the system may lead to rash practice 
 and the attempt to do things which had better be left alone, and 
 knowing, also, how difficult it is to obtain any trustworthy, statis- 
 tical, comparative facts to determine the relative success of any 
 operation well performed, with and without antiseptic precau- 
 tions — all other things being equal — I think what I have said of 
 my own observations, although they only amount to twenty-two 
 cases, may have some little value.'' What Mr. Wells complains 
 of here is, I think, a very just object of criticism. The argument 
 of many of the supporters of Mr. Lister's theories, and the pro- 
 mulgators of his practice, use an argument very like the school- 
 boy catch, " Heads you lose, tails I win." If there is success, 
 then it is Listerism; if there is failure, then it is not Listerism; 
 some important detail, like Mr. Wells' clamp, has been improp- 
 erly managed, and the failure is no fault of the system. 
 Another method of their argument is to say that their opponents, 
 having no faith in the system, can have neither honesty nor in- 
 telligence sufficient to carry it out. To such a method of discus- 
 sion it is impossible to reply with courtesy; and my only answer 
 is that, as it is my best interest to cure my patient, I am ready 
 and, I believe, capable of applying any practice for that pur- 
 pose, but that I do not care willingly to approach the land of 
 quackery. 
 
 Since Mr. Wells delivered his lectures he has seen reason to 
 change his opinions, and he now attributes his diminished mor- 
 tality to the introduction of antiseptics. There is this difficulty, 
 however, left for him to explain : his mortality now is double 
 that which Dr. Keith had secured before he used antiseptics at 
 all, and at a time when Dr. Keith's experience was little more 
 than a fifth of what Mr. Wells' is at present. 
 
 I think it very likely that if my own results with the Listerian 
 details had been bad, it would have been said that I did not 
 understand the system, and never could, and I think the charge, 
 probably, would have been correct. But my results were good, 
 and therefore they were allowed to pass. But I really believe 
 that very few of my cases would have been admitted by an 
 enthusiastic Listerian, and I am quite sure that for the last two 
 years not a single case would have passed muster. Whether or 
 not that be so, here are the results of the whole of my practice 
 up to the date of my writing this : 
 
 Per cent. Mortality, 
 
 Ligature, non-antiseptic ( 1 87 cases) 3.74: 
 
 Ligature, antiseptic (52 cases) 3.84 
 
 Clamps, non-antiseptic (30 cases) 25.00 
 
 Clamps, antiseptic (26 cases) 27.00
 
 276. DISEASES OF THE OVARIES. 
 
 Can any reasonable being doubt that here the improvement 
 lies in the giving up of the clamp? In the figures for the " anti- 
 septic ligature " I give credit for twenty-two consecutive re- 
 coveries in which Listerism was not really complete, as Mr. 
 Listers dressings were never used, nothing but plain dry cotton 
 wool being put upon the wounds, and if the results had been 
 bad among these, my Listerism would be scouted. If I put 
 these cases to the credit of ''non-antiseptic ligature," as I very 
 fairly might, then the account would stand thus : 
 
 Per cent. Mortality, 
 
 Non-antiseptic ligature (209 cases) 3.00 
 
 Antiseptic ligature (30 cases) 6.6 
 
 Thus it is that I am very hard of belief about the merits of 
 the Listerian details as applied to ovariotomy, the more so as I 
 have carried out all the processes with plain cold water, and got 
 quite good results, and I find that the chief advocates of the 
 '' antiseptic system," those who attribute their success to it, never 
 get their mortality lower than ten or twelve per cent., whereas 
 without it I keep under five per cent. I can regard this sudden 
 love for the antiseptic system as nothing but a shield to cover 
 the retreat from the use of the clamp. 
 
 Mr. Spencer Wells' last utterances on the question of Lister- 
 ism are very important. In his recently published work on 
 "Ovarian and Uterine Tumours" he says: "Four of my last 
 sixteen deaths were caused by septicaemia, so that antisepticism 
 has not abolished this plague of abdominal surgery. Lister's 
 antiseptic plans have not brought me to the point of seeing no 
 deaths from septicaemia, as promised by some of their enthusi- 
 astic promoters, nor have they advanced my success in operating 
 beyond what was obtained without it." These words seem to 
 me to contain a practical and complete admission of what I have 
 always contended, that Mr. Wells' greater success was due to 
 his giving up the clamp. The mortality of his first 800 cases was 
 25.5 per cent., while in the subsequent 200 it was only 14.5. 
 
 My views received very valuable support from Dr. Granville 
 Bantock, Senior Surgeon to the London Samaritan Hospital, in 
 a letter he published in the British Medical Journal for January 
 8, 1881, from which I take the following extract : 
 
 "I quite concur with Mr. Lawson Tait, when he says that 
 * the method of recovery ' is of far more value in estimating the 
 merits of any particular system than ' the mere death-rate,' 
 which is often a matter of luck, and especially when the differ- 
 ence in the latter is measured by units. I further agree with 
 him in attributing to the present mode of treating the pedicle
 
 OVARIOTOMY. 277 
 
 much of the success which has recently been achieved. If there 
 is one thing more than anotlier, in the matter of ovariotomy, to 
 which I look back with satisfaction, it is to the persistency with 
 which I held to and urged the systematic use of the ligature at 
 a time when (in 1875), owing to the powerful and sustained 
 advocacy of Mr. Spencer Wells, the clamp was at the zenith of 
 its fame. Notwithstanding the excellent results obtained by 
 Dr. Tyler Smith, the ligature had fallen into unmerited obliv- 
 ion, and was at that time used only as a dernier ressort, and in 
 the most desperate cases. Thus, Mr. Wells says (at page 3G1 of 
 his book), ' you will hardly wonder that I use the clamp when- 
 ever I can ;' and at page 371, he says, ' the more I see of ovario- 
 tomy .... and the more I am driven to resort to cautery 
 or ligature, the less I am satisfied with the results of these 
 methods, the more reluctant am I to employ them, and the 
 greater is my confidence in the clamp,' etc. The evidence I 
 produced in favor of the ligature, as far back as 1872, before the 
 Obstetrical Society, appears to have missed that notice which is 
 claimed, and which subsequent events have shown it to have 
 deserved." 
 
 Dr. Keith, in the record of his cases, does not give completely 
 such details as afford a perfect statement of his results, based 
 upon the various methods of treating the pedicle ; but he tells us 
 that in his first 50 cases he used the clamp 48 times, with 9 
 deaths. In his second 50 he merely indicates that his confidence 
 in the cautery is returning. In his third 50, the clamp was used 
 34 times, with 7 deaths, and the cautery and short ligature 15 
 times, without a death ; and now I understand from himself that 
 he has entirely abandoned the extra-peritoneal method of dealing 
 with the pedicle, as, indeed, has everybody else, by reason of Dr. 
 Keith's unprecedented success with the intra-peritoneal method, 
 even before he adopted antiseptics. 
 
 The basis of the antiseptic claim is that the system prevents 
 septic poisoning, that is, septic or surgical fever. Every one 
 who has watched a number of ovariotomies knows that by far 
 the larger number of deaths occur from the incidence of fever, 
 and that the pulse and temperature rise progressively, though 
 perhaps with intermissions, till they reach the fatal vanishing 
 points. With few exceptions this is true of all the deaths I have 
 had. If, therefore, the antiseptic system favors a larger num- 
 ber of recoveries hj preventing the so-called septic fever, it is 
 an absolute certainty tliat the recoveries will be uniformly and 
 correspondingly facilitated, inasmuch as in non-antiseptic cases 
 the germs will enter every peritoneum and will theoretically pro- 
 duce fever in every case, and only in those cases where there is
 
 278 DISEASES OF THE OVAKIES. 
 
 a sufficiency of an unknown something which counteracts the 
 septic poison will recovery be obtained. 
 
 Equally according to the theory will the germs destroyed by 
 the antiseptic precautions enter the peritoneal cavity harmlessly, 
 being dead and unfit to produce septic fever. 
 
 Another step in the syllogism is that as the temperature and 
 pulse curve are uniformly admitted to represent the course of 
 any case involving febrile action, if the antiseptic system makes 
 its claims justly, ovariotomies performed under its precautions 
 ought to indicate a more even and less febrile course of re- 
 covery than the non-antiseptic cases, and this should occur in- 
 dependently of all other details of the operation. 
 
 I would put the possible conclusion briefly thus : If we find 
 a marked difference between the curves of cases treated anti- 
 septically and those not so in favor of the former, then I think 
 I may say that more has been done to establish Mr. Listers 
 view than anything I have yet seen. If there be no difference, 
 then the question is just where it was ; but if there be a differ- 
 ence on the other side, then I think the application of the germ 
 theory to surgical practice will be certain to fade away from 
 professional and popular acceptance just as many fair-looking 
 visions have done before. 
 
 In order to test this point as far as I could I took the morn- 
 ing and evening observations of the temperature and pulse for 
 each case during a period of ten days, and constructed for the 
 morning and evening of each day an average of the total obser- 
 vations under discussion, and marked this upon graphic paper. 
 I took ten days as the limit, because I believed that this ex- 
 ceeded by at least three days the average period of stable re- 
 covery in cases of ovariotomy, and because it was the limit to 
 which the observations could be extended with full material. 
 My general impression was that a successful ovariotomy was 
 practically well on the sixth day ; but it will be seen from the 
 figures that, like other general impressions, this is quite a mis- 
 take, for convalescence is not fully established till the eighth 
 day, and is certainly not complete on the tenth. Therefore, 
 probably my conclusions would have been better with more ex- 
 tended observations. I also see now that my statements would 
 have been more perfect if I had carried out my figures to two 
 or even three places, but this would have involved a great 
 amount of labor. 
 
 Concerning the mere duration of recovery, some interesting 
 conclusions were indicated. From the curves which I con- 
 structed from the whole of the one hundred cases, it is quite 
 evident from the pulse curve, still more from the temperature
 
 0VARI0T03IY. 279 
 
 curve, that recovery takes a sudden progress forward on the 
 eighth day, but that it is not then complete. On the sixth and 
 seventh days the temperature gives distinct indications of exal- 
 tation, especially nocturnal, and this is clearly seen, on exami- 
 nation of the constituent curves, to be due to the suppuration 
 consequent on the separation of the clamp, and probably, also, 
 on the formation of stitch-hole abscesses. 
 
 The consideration of this curve leads me to say that I attach 
 less value to the temperature curves than to the pulse curves, 
 for the reason that the temperature during the course of recov- 
 ery from ovariotomy is liable to extraordinary explosions. I 
 have repeatedly seen a patient's temperature rise three or four 
 degrees, and in one recent case six degrees centigrade, without 
 the slightest apparent reason, the exaltation lasting from half 
 an hour to three or four hours, and then the temperature would 
 fall quite as rapidly, leaving the patient without any appear- 
 ance of effect, or any record of it, save on the chart. This is not 
 the case with the pulse curve, for if that rises the general ap- 
 pearance of the patient, and other signs and symptoms, amply 
 prove that something is wrong, and the changes of the curve do 
 not occur or give way with rapidity, but always gradually. 
 Therefore, temperature readings require to be far more numer- 
 ous than pulse readings to give the same uniformity of result. 
 Pulse readings are also not subject to such influence by limited 
 suppuration as temperature readings, and this is shown by the 
 marked difference in the temperature and pulse curves on the 
 sixth and seventh days. Further, the temperature rises almost 
 uniformly at night during the progress of recovery, while the 
 pulse does not do s > after the fourth night, and this confirms 
 my general impression that the fourth night is tlie critical 
 night of the course of an ovariotomy. My conclusion is finally 
 confirmed by the fact that, while I have seen a case end badly 
 without the temperature rising to any remarkable height, I 
 have invariably found the pulse rise continuously till it disap- 
 peared. 
 
 It is made almost certain by all that I have seen, as far as 
 my practice is concerned at least, that the improvement is due 
 chiefiy to the introduction of the intra-peritoueal treatment of 
 the pedicle, and as far as I can discover there is nothing to be 
 credited to antiseptic precautions, for the difference in result 
 between the ligature used under antiseptic precautions and with- 
 out them is not worth discussing, and depends really upon one 
 death in one hundred and thirty-nine cases, and that death was 
 not due in any either to septics or antiseptics, but would have 
 occurred in any case. I have seen a case killed by thymol, and
 
 280 DISEASES OF THE OVAKIES. 
 
 this agent has been, by common consent, quite abandoned. Per- 
 haps I have never seen carbolic acid kill a patient, as it is used 
 now, but I have seen it produce very serious symptoms, and, 
 therefore, I have entirely discontinued Mr. Lister s practice in 
 abdominal surgery save in such cases as those conjointly respon- 
 sible with myself desire that it should be employed. The only 
 detail I have retained is the practice of having my instruments 
 in a water-bath, which I find to be an easy and effective method 
 of keeping them clean. 
 
 Dr. Keith has quite recently come to somewhat similar con- 
 clusions, and he has given up Listerism for abdominal surgery, 
 and he told us at the recent International Congress, in London, 
 that Listerism would add two or three per cent, to the mortality 
 of ovariotomy. I am certain he is right. 
 
 For ovariotomy I generally have the patient" anaesthetized on 
 the bed and then lifted upon the table, the object of this being 
 that she is saved the distress of seeing the preparations which 
 have been made for the operation, as the instruments and other 
 appliances are not brought into the room until she is uncon- 
 scious. When upon the table, the arms and legs are secured by 
 belts, and two clean towels are arranged so as to leave the abdo- 
 men exposed between them. I prefer this method to the rubber 
 cloth with a hole cut in it, originally used by the late Sir William 
 Ferguson, for it entails difficulty in securing the latter to the 
 patient's skin, and, as a rule, I have not found that it saves very 
 much mess. The bladder has previously been emptied by the 
 nurse, and I have personally inspected all the arrangements of 
 instruments, sponges, etc., to see that nothing has been omitted. 
 
 I begin the incision midway between the umbilicus and the 
 pubes and cut downward, going completely through the skin 
 and subcutaneous fat at one cut, for a distance of about two and 
 a half inches. I then look for the white line and divide it to an 
 equal extent, and after that I cautiously divide the fat and trans- 
 versalis fascia until the peritoneum is exposed. A pause is then 
 made, and every bleeding point is secured by a pair of scissor- 
 forceps. I never, in the first instance, make an incision any 
 longer than two and a half inches, because I am very averse to 
 making the wound any larger than it need be, and, ,as a rule, 
 three inches is enough. As soon as all the bleeding points have 
 been secured, I open the peritoneum so as to admit my forefin- 
 ger, and with that I make a brief preliminary exploration. The 
 peritoneum is then laid open to an extent corresponding with 
 the wound in the other tissues and the cyst is expos^ed, any fur- 
 ther bleeding being immediately arrested. In this stage of the 
 operation, indeed throughout the entire proceeding, I never use
 
 OVARIOTOMY. 281 
 
 any other director than my finger, for upon that I can place 
 most rehance. If there should be no adhesions between the 
 tumor and the peritoneum in front, this part of the operation 
 is very simple; but if there be adhesions it is often no easy mat- 
 ter to determine the point of union between the two membranes, 
 and it is in such a state of matters that inexperienced operators 
 are apt to commit a grievous error. I have twice known in- 
 stances, and I have heard of several others, where the glistening 
 peritoneum has been mistaken for the wall of the cyst, and the 
 operators have industriously set to work to separate the former 
 membrane from the transversalis fascia. Sometimes, even when 
 there is no adhesion, the peritoneum is so greatly altered in ap- 
 pearance, having become so thick, leathery, and gelatinous, as 
 to deceive any but the most experienced operator. When the 
 point of union between the cyst and peritoneum cannot be dis- 
 covered, the best way is to cut cautiously inward until the cyst 
 be opened, because then it can be emptied, the whole wall care- 
 fully taken up and examined, and the several parts accurately 
 determined. This, however, wants great caution, for it may be 
 that a piece of intestine lies in the way and may be opened by 
 mistake ; but the experiences of a few cases will enable an ob- 
 servant surgeon easily to determine when he is cutting through 
 muscular fibre. When the cyst is reached, it should be tapped 
 by a large-sized syphon trocar (Fig. 31, p. 2G1) and emptied as 
 quickly as possible. Sometimes, however, the contents of an 
 ovarian cystoma are glairy or even perfectly gelatinous and will 
 not pass through a trocar, and nothing tries the presence of mind 
 of an inexperienced operator more than this. The peculiar ad- 
 hesive mass which sometimes fills an ovarian cyst will neither 
 pass through a trocar, nor be seized by the hand nor lifted up by 
 a sponge, and to remove it from the cyst is often a matter of the 
 greatest difficulty. It was upon such a tumor as this that Hous- 
 ton performed the first ovariotomy. In such a case the walls of 
 the cyst are generally thin and extremely fragile, so that they 
 cannot be held by forceps. Such tumors are also often very ad- 
 "herent, the adhesions bleeding very freely when broken down, 
 and many of these cases are lost on account of the mere exten- 
 sion of time required for the removal of the cyst contents.' In 
 a case like this there is nothing for it but to enlarge the incision 
 to the extent of four or five inches, or even more, and to remove 
 the mass by the hands as rapidly as possible, the assistant aid- 
 
 ' In a pretty table (III.) in his book Resultats Statistiques de I'Ovariotomie, M. Koe- 
 berle shows conclusively how fatal protracted operations are. It follows, therefore, 
 that in cases of difficulty — and these are the only fatal ones — an experienced, skilful, 
 and rapid operator is sure to have by far the best results.
 
 282 DISEASES OF THE OVARIES. 
 
 ing in the process by squeezing upon the flanks. If, however, 
 the cyst contents are fluid and the tumor consists mainly of one 
 cyst without adhesions, nothing would seem more simple than 
 an ovariotomy, and the removal of a parovarian cyst is usually 
 a proceeding which takes a shorter time to perform than to de- 
 scribe. 
 
 When the cyst has been emptied, it should be drawn gently 
 out through the wound ; and if non-adherent, no obstacle will 
 be met with unless it be the presence of some secondary cysts. 
 The trocar having been maintained in its position by means of 
 the spring catches at its sides, its point should be made to enter 
 these cysts, and thus empty them ; but very often the contents 
 of these secondary cysts are much thicker than the fluid con- 
 tained in the major ones, and sometimes they are so numerous 
 and of such small size that they constitute a solid mass at the 
 base of the tumor. In such a case I lay open the major cyst, 
 and, passing my hand within it, I break up into its cavity as 
 much as I can of the secondary cyst mass, in order to save any 
 further enlargement of the abdominal wound. During the 
 whole of these proceedings as much care as possible should be 
 taken to prevent any escape of the cyst contents into the ab- 
 dominal cavity. 
 
 Adhesions are mediate or immediate, the former being gen- 
 erally parietal or omental, existing in the shape of round or flat- 
 tened bands of peritoneum. They seem to be formed by isolated 
 patches of adhesion, which have dragged off the peritoneum from 
 the abdominal wall, or by pieces of adherent omentum. They 
 are seldom large, and are only of any moment when traversed 
 by an important blood-vessel, which must always be secured by 
 torsion or ligature, or by the cautery. The immediate adhe- 
 sions require great patience to overcome them ; but even when 
 they unite the tumors to the most important organs, they may be 
 separated, or a piece of the cyst may be detached and left. One 
 of the dangers of the removal of an ovarian tumor with exten- 
 sive pelvic adhesions — and still more of a uterine tumor — is 
 damage to one or both ureters. It will be remembered thatr 
 they run down obliquely from the kidney over the brim of the 
 pelvis down to the bladder, lying over on each side of the cer- 
 vix, and close to it. I have often laid them bare, but have never 
 been unfortunate enough to injure them. In the celebrated case 
 published by Simon {Chirurgie der Nieren., 1870), the ureter 
 had been dragged into the wound and clamped, and the pa- 
 tient recovered, with a urinary fistula of the left ureter. Simon 
 heroically removed the left kidney and cured his patient, and 
 I saw her alive some years after the operation, and at the
 
 OVARIOTOMY. 283 
 
 same time I saw her tumor in one bottle and her left kidney in 
 another. 
 
 Nussbaum had a similar accident, and he cured his patient 
 by making an artificial continuation of the ureter between its 
 divided points. When dividing the pedicle of a large tumor of 
 old standing, I have several times seen hugely dilated lyinphatic 
 trunks, which looked very much like ureters — a resemblance 
 which more than once made me very uncomfortable for a few 
 days. 
 
 Many curious and exceptional forms of adhesion occur, one 
 of the most remarkable of which is occasional adhesion of the tip 
 of the vermiform appendix of the caecum to the tumor. I have 
 seen this three times, twice in my own practice. The first time 
 I saw it it was unfortunately divided by the scissors of the oper- 
 ating surgeon, with a fatal result ; and it was only the discovery 
 of this misfortune at the post-mortem which enabled me to re- 
 cognize a similar condition, and avoid a like disaster in my own 
 cases. In dealing with pelvic adhesions it must be borne in 
 mind that the large venous trunks in that region lie immediately 
 under the peritoneum, and that they must be carefully avoided. 
 In the first operation I ever saw, one of these trunks was torn 
 across by the rough handling of an inexperienced operator, and 
 I need hardly say that death ensued in a very few hours, be- 
 cause it was quite impossible to secure the bleeding point, or 
 even to find it. Immediate death was only staved off by stuf- 
 fing the pelvis with a towel. This event made such a strong 
 impression upon me that I thought it hardly possible I ever 
 could take part myself in an operation fraught with such terri- 
 ble risks. Hemorrhage from adhesions has always a very 
 strong tendency to arrest itself, and most of the bleeding points 
 will stop of their own accord, or can be stopped by simple pres- 
 sure with a sponge ; each point of importance should be seized 
 by a pair of scissor-forceps, or touched with a cautery, or with 
 a piece of solid perchloride of iron. For the arrest of a general 
 oozing from a large surface, the pressure of two or three dried 
 sponges is generally enough, and it is, therefore, my practice 
 always to separate adhesions as rapidly as possible, and to fol- 
 low their separation by the immediate application of sponges, 
 leaving these in situ until I have finished the separation and re- 
 moval of the tumor. ' 
 
 ' A few (lays ago I removed a tumor universally adherent, full of pus, and quite 
 rotten. I tore across the pedicle before I had recognized it, and its vessels bled pro- 
 fusely. Like the rest of the tissue, it was qiaite rotten, and the more I tied the ves- 
 sels the more they bled. The cautery was equally useless. I therefore secured all 
 the points by means of forceps, and left them in situ in the abdomen, closing the
 
 284 DISEASES OF THE OVARIES. 
 
 Suppose the tumor separated and withdrawn, the assistant, 
 stationed opposite tlie operator, should immediately insert one 
 or two sponges to prevent the exit of the intestines, and he 
 should then take possession of the tumor and steady it while 
 the surgeon examines the pedicle, and determines how it may 
 best be dealt with. 
 
 At present, we may say, there are only three methods in 
 vogue for the treatment of the pedicle, and of these one — that is, 
 the clamp— should be reserved for extremely exceptional in- 
 stances. Probably not more than two or three cases in a hun- 
 dred require now to be dealt with by the clamp ; certainly, I 
 have not met with more than one for the last three years. The 
 kind of pedicle requiring the clamp is thick and soft, and so 
 short as to contain, perhaps, a small piece of the tumor. With 
 such a pedicle the extra-peritoneal method is admissible, and 
 probably is superior to treatment either by the cautery or the 
 ligature ; but I am not quite sure that a combination of a drain- 
 age-tube with either of these latter methods may not yet be 
 found superior to the clamp. If to the pedicle of an ovarian 
 tumor, unusually thick and short, or in that of a uterine tumor, 
 it is thought desirable to employ a clamp, then it' is evident that 
 what is wanted is a form of circular constriction by some means 
 which will completely arrest the hemorrhage, will not cut the 
 pedicle, and which will allow the wound to be accurately ad- 
 justed round the stump. 
 
 To meet all these requirements, I have devised a clamp 
 (figured on opposite page) which has served my purpose better 
 than any I have seen. 
 
 After a large number of experiments I selected thick copper 
 wire (No. 12, Birmingham gauge), nickeled, and completely soft- 
 ened by being made red hot and allowed slowly to cool, as being 
 the best material to work with. 
 
 For use I bend it into a loop, as seen in the right-hand figure, 
 ready for the operation. After it has been placed round the 
 pedicle, the collar B is run on close up to the pedicle. The han- 
 dle A E \% then also run on, the ends of the wires running in 
 the holes F F, and the end A fitting into a counter-sunk hole, 
 shown by a dotted line at B. The pinch-screws D D are then 
 closed tightly down on the wires, the screws C C being quite 
 loose. The handle at E is then turned slowly till the loop of 
 wire firmly constricts the pedicle. The tumor is then removed, 
 and if there be any bleeding, a few more turns of the handle F 
 
 wound over them. I reopened it in twenty-four hours, removed the forceps, refast- 
 ened the wound with a drainage-tube at its lower angle, and the patient made an un- 
 interrupted recovery.
 
 OVARIOTOMY. 
 
 285 
 
 will secure it. When this is done, the pinch-screws C C are to 
 be securely tightened down on the wire, and those at D D loos- 
 ened. The handle will then come off, leaving the wire clamp 
 with its collar, as seen in the right-hand figure. The ends of 
 the wire are then to be turned slightly up, and the wound closed 
 and dressed as usual. 
 
 I have used this clamp in thick pedicles in eleven cases with 
 perfect success, and six of those were uterine myomata. 
 
 Of the two intra-peritoneal methods of dealing with the pedi- 
 cle, which, by common consent, have been adopted as superior to 
 all others, it is as yet extremely difficult to give preference to 
 one over the other. In the hands of Dr. Keith, the cautery, as 
 originally introduced by Mr. Baker Brown, has been brilliantly 
 
 Fig. 33.— Tait's Wire Clamp. 
 
 successful ; but in my own hands the silk ligature has proved 
 not one bit inferior ; and I shall retain it as long as it serves me 
 as it has done up to the present moment ; for it could only be by 
 careful comparison of the results of a very extended experience 
 that any determination would be arrived at as to the superiority 
 of the one over the other. As soon as Dr. Keith has removed 
 the tumor, he fastens on the pedicle the well-known cautery 
 clamp of Mr. Baker Brown, screwing it up very tightly ; he 
 then divides the pedicle above the clamp by a common cautery 
 iron at a dull red or almost black heat, searing the pedicle very 
 slowly, but very completely. When he removes the clamp, that 
 part of the pedicle which has been embraced by it is shrivelled 
 and translucent, like parchment, and it very rarely gives him any
 
 286 DISEASES OF THE OVARIES. 
 
 further trouble by bleeding ; if it should do so, he screws it up 
 again and applies the iron more effectually. He then drops the 
 pedicle back into the cavity and proceeds with the further steps 
 of the operation. I have watched him go through the process 
 with great interest, but I was not impressed by anything beyond 
 my previous convictions, that it is the intra-peritoneal method, 
 and not any particular variety of it, which gives the success ; 
 and that the ligature as applied in " Tait's knot" occupies less 
 than a tenth part of the time taken by the cautery, and, I think, 
 must be more secure. 
 
 The history of the short ligature is given as follows by Mr. 
 Alban Dor an (St. Bartliolomeivs Hospital Reports, 1877) : 
 
 '' But Dr. Nathan Smith, of Connecticut, the second American 
 ovariotomist, in his first operation in 1821, not only ligatured 
 two arteries in the omentum with strips of leather from a kid 
 glove, but also tied two arteries in the pedicle. This is in ac- 
 cordance with principles recognized by the most experienced 
 modern operators, ligature of the pedicle, as a whole, being 
 hazardous, since the single thread is apt to snap. The ends of 
 all the ligatures were cut short, and the external wound closed, 
 the stump of the pedicle having been returned into the abdom- 
 inal cavity. Dr. Smith, then, was the first to adopt the com- 
 plete intra-peritoneal ligature. The patient recovered. 
 
 "• In 1829 Dr. David Rogers, of New York, ligatured separ- 
 ately several large vessels in the pedicle of an ovarian cyst, and 
 returned the stump of the pedicle, with the ligatures cut short. 
 The operation was perfectly successful. In 1835 Dr. Billinger 
 adopted the same proceeding, with satisfactory results. 
 
 *• Dr. Tyler Smith appears to have been the first authority 
 who regularly and systematically advocated complete intra-peri- 
 toneal ligature. Recently it has been adopted in hundreds of 
 successful cases where the pedicle has been found too short for 
 the clamp to be safely applied. Ligatures of bleeding vessels in 
 omentum are also cut short. As many as forty ligatures have 
 been left in the abdominal cavity without any evil effects." 
 
 My own method of dealing with the pedicle is by a piece of 
 silk thread, varying in thickness according to the mass of the 
 pedicle ; for a thin pedicle I use thin silk, and for a thick pedicle 
 correspondingly thick cord, because, of course, in the latter case 
 the ligature must be pulled with much more force than in the 
 former. The method in which I use the ligature is that I have 
 termed the Staffordshire knot, as it is the badge of the county of 
 Stafford; and the idea of its use occurred to me while travel- 
 ling in a Staffordshire railway carriage, in which it was a con- 
 spicuous ornament. Mr. Mazzinghi, the learned custodian of
 
 OVAKIOTOMY. 287 
 
 the William Salt Library at Stafford, tells me that nothing is 
 known definitely as to the origin of the badge, further than that 
 it was granted by the College of Heralds to the county within 
 living memory, and was copied from the arms of the old Staf- 
 ford family at Maxstoke Castle. Such badges were used to dis- 
 tinguish the adherents of noble families, and their origin is 
 generally altogether unknown. The legend in the present case 
 is that rogues were at one time so numerous in Staffordshire 
 that a knot had to be devised which would hang three at a time. 
 If so, the original knot must have differed from its present 
 representative, for the latter could only hang two. It is, how- 
 ever, its remarkable property in this direc- 
 tion which has led me to introduce its use 
 in surgery. 
 
 The woodcut will show how the knot 
 acts, and a very brief description will prob- 
 ably make clear enough how it is used. 
 
 ■ T . ni n i-ji Fig. 3-1. — Tait'B " StaflEordsliire 
 
 An ordinary-handled needle, armed with a Knot." 
 
 long piece of the silk required, is passed 
 
 through the pedicle and then withdrawn so as to leave a loop on 
 the distal side. This loop is then drawn over the ovary or tumor, 
 and one of the free ends drawn through it, so that one end is 
 above, while the other is under, the retracted loop. Both ends 
 being seized in the hand, they are drawn through the pedicle, 
 against which the thumb and forefinger of the left hand are 
 pressed as a fulcrum, till complete constriction is made. A sim- 
 ple hitch is then made, as in the drawing, and tightened ; and 
 that is followed by another, as in ordinary ligature-tying. There 
 is another and more complicated way of making the knot, by 
 passing each end of the thread round the corresponding half of 
 the pedicle, and crossing them within the loop in front, which is 
 equally effective, and which may be used in cases of large solid 
 tumors. But the former way is by far the more elegant and 
 rapid method. 
 
 The advantages of this knot over all others are that, while it 
 ties the pedicle in two halves, these halves are compressed 
 really into one surface ; the two halves are equally well com- 
 pressed ; and, from the mechanical arrangement of the knot, 
 very great constricting force can be employed ; and in this re- 
 spect it greatly excels Dr. Peaslee's chain-ligature. I have used 
 it now about two hundred times and it has never failed me on 
 one single occasion. I cut the pedicle through about a quarter 
 of an inch on the distal side of the ligature and drop it back. 
 It may very reasonably be asked what becomes of a ligature so 
 disposed of, and, fortunately for me, I am wholly unable to
 
 288 DISEASES OF THE OVAEIES. 
 
 answer the question, for I have not yet had an opportunity of 
 seeing one on which I have placed it. I therefore gladly accept 
 the description given by Mr. Alban Doran, in the St. Bartholo- 
 mew's Hospital Reports for 1877 : 
 
 "In 1872 Dr. Bantock exhibited before the Obstetrical Society 
 the stump of an ovarian pedicle from a patient who died of 
 cancer one year after double ovariotomy had been performed 
 upon her. The hempen ligature applied, with its ends cut short, 
 to one of the pedicles, was found on dissection to have been 
 completely absorbed, excepting its knot, which remained as a 
 hard body the size of a hemp-seed, covered b}^ peritoneum. 
 The bulging of the tissues over each side of the groove formed 
 by the ligature had brought the strangulated portion of the 
 stump at once into close contact with the unstrangulated proxi- 
 mal part. Through the slight irritation produced at first by the 
 pressure of the ligature, the proximal part had thrown out 
 plastic lymph, which had conveyed nutritive plasma and also 
 capillaries to the distal portion of the stump, and thus saved 
 it from gangrene. In a case like this, the stump ultimately 
 atrophies, for reasons evident to any surgeon with a superficial 
 knowledge of pathology. As for the ligature, it is destroyed in 
 the manner demonstrated by the experiments of Spiegelberg^ 
 and Waldeyer." 
 
 Hegar has described a case where the pedicle sloughed and 
 was passed en masse by the rectum, and on it was found the liga- 
 ture which had been applied. The patient passed successfully 
 through this terrible ordeal, and I hope her accident will remain 
 without imitation. 
 
 The next step of the operation is to examine the other ovary, 
 and if this be found diseased, to remove it in a similar way ; and 
 I cannot help thinking that the cases are much more numerous 
 than they used to be in which it is becoming necessary to re- 
 move the second ovary on account of cystic growth. Certainly, 
 both in my own practice and in those of others which I have had 
 an opportunity of seeing, the second ovary has been diseased 
 and has required removal more frequently than used to be the 
 case. 
 
 An exceptional method of dealing with the pedicle — the one 
 introduced by Dr. Miner and called enucleation — deserves no- 
 tice, because it must occasionally be resorted to in cases of sessile 
 tumors. It is by no means easy of performance and always 
 gives rise to very troublesome hemorrhage. This method con- 
 sists in opening the peritoneal capsule at the base of the tumor, 
 and scratching or dissecting out the cyst from the matrix in 
 which its base is placed. Each bleeding point must be carefully
 
 OVARIOTOMY. 289 
 
 secured as it is divided, and when the tumor is removed the 
 peritoneal stump must be gathered together and the edges fas- 
 tened by sutures, just as in an amputation. I have three times 
 employed this method with eminently satisfactory results ; but I 
 am bound to say that without a good deal of experience in the 
 separation of adhesions I would have stopped in the middle of 
 the process and left it incomplete, on account of its difficulties. 
 
 The next duty of the surgeon is to carefully cleanse the perito- 
 neal cavity from all blood-clots and other debris which may be in 
 it. For the introduction of this practice and the extreme care with 
 which it is now done, as well as for the excellent results obtained 
 from it, we are entirely indebted to Dr. Keith, though we find 
 that he was partly anticipated by McDowell, who tells us, in his 
 description of second operation: "Notwithstanding my great 
 care, a quart or more of blood escaped into the abdomen; and, 
 after the hemorrhage ceased, I removed, as cleanly as possible, 
 the blood, in which the bowels were completely enveloped." So 
 highly important do I consider careful attention to this precau- 
 tion that I make no apology for giving the following some- 
 what lengthy extract from Dr. Marion Sims' description of Dr. 
 Keith's method : 
 
 " When Dr. Keith performed his first operation in 1862, he 
 was surrounded by old men in the profession who had a dread 
 of wounding the peritoneum continually before their eyes. He 
 was obliged to break up extensive adhesions, and, as a conse- 
 quence, there was free exudation of blood. Before closing the 
 external wound he began to sponge out the peritoneal cavity 
 and suddenly thrust a large sponge down into the pelvis and 
 brought it up saturated with blood. Squeezing it dry, he was 
 about to repeat this process, when they all united in begging him 
 not to do it, as from their stand-point there would be more danger 
 in irritating the delicate peritoneum with the sponge than by 
 leaving the blood there to be absorbed. He yielded against his 
 judgment and closed the wound, leaving a large quantity of 
 blood in the peritoneal cavity. On the third day afterward his 
 patient was profoundly septicaemic, and in imminent danger. 
 He recognized the source of danger and had the courage to open 
 the lower angle of the wound, by removing two or three sutures. 
 There was an immediate discharge of fetid bloody serum in 
 large quantities, and from that moment the patient began to im- 
 prove and soon got well. This made a profound impression on 
 Dr. Keith's mind, and he determined from that time never again 
 to leave extravasated blood in the peritoneal cavity if he could 
 possibly remove it. It was not long before he had an oppor- 
 tunity of putting this principle to the test of experiment, for his 
 19
 
 290 DISEASES OF THE OVARIES. 
 
 second case was a very bad one, with extensive adhesion. He 
 had to tie many vessels and bleeding points. There was a large 
 exudation of blood in the pelvic cavity, and he sponged it all out 
 thoroughly, after which he closed up the external wound, and his 
 patient recovered without a single bad symptom. From this time 
 he adopted the principle of never closing an external wound till 
 he had controlled all oozing of blood and made sure that the peri- 
 toneal cavity was dry and clean." I have seen Dr. Keith do this, 
 and there can be no doubt that in this, as in other respects, he 
 has greatly added to the success of ovariotomy. 
 
 This process has been called by the German surgeons the 
 "toilet " of the peritoneum, and no care can be too great in its 
 performance. I generally clean out the cavity of the pelvis and 
 the hollow of each loin by two or three sponges, and then fill the 
 whole abdomen full of tepid water by means of a tube running 
 from a ewer or a suspended cistern, closing the wound as well as 
 I can with one hand while the other is inside. I move my fingers 
 rapidly about among the intestines and give them a good wash 
 in the water. I then empty the cavity and refill ifc two or three 
 times until the water comes out quite clear. In this way I very 
 rapidly determine if there is any bleeding, because even a small 
 point will perceptibly tinge the water I have poured in ; and if 
 the water continues colored I immediately hunt about until I 
 have found and secured the bleeding point. After the cleansing 
 has been satisfactorily accomplished I put a number of dry 
 sponges down in the pelvis and over each kidney and then pro- 
 ceed to insert the sutures in the wound. By the time this is ac- 
 complished the dry sponges have soaked up all the water, and the 
 peritoneum is generally found quite clean and dry. But if it 
 should not be satisfactorily so, I repeat the process until I am 
 quite certain nothing has been left behind, and in this way I be- 
 lieve I have added largely to the success of my practice. 
 
 Dr. Keith places great reliance on the use of drainage-tubes as 
 originally introduced by Koeberle in 1867, and improved by him- 
 self ; and this is a practice I have employed frequently of late and 
 I think with very great advantage. Dr. Keith used to think the 
 Listerian method obviated the necessity for drainage, and that by 
 its employment any fluid left in the abdomen was prevented from 
 decomposing ; but my own experience satisfies me that neither 
 of them need be used if the abdomen can be properly cleansed 
 and dried. Dr. Keith has now given up Listerism and his re- 
 sults are quite as good without it as with it, perhaps better, for 
 he has had two deaths from carbolic acid poisoning. I think the 
 peritoneum itself will do a great deal of work in removing the 
 debris J but the surgeon's object should be to give it as little un-
 
 OVARIOTOMY. 291 
 
 necessary employment as possible, and therefore I adhere most 
 closely to Dr. Keith's practice in this respect, and to it I may 
 largely attribute my increased success. Finally, I take the ut- 
 most care with the sutures to see that they are ranged evenly, 
 that they include all the structures of the abdominal wall,' that 
 the stitch-holes do not bleed, and that the wound is most accurate- 
 ly closed. I am never satisfied to leave an eighth of an inch of 
 gaping wound, and I take the utmost care that the edges of the 
 skin are in correct adaptation. I always use silk sutures, and in- 
 troduce them generally by means of a large crochet needle. In 
 fastening the sutures, as well as in tying all 
 ligatures which are not transfixed, I always 
 use the knot here figured, having two turns 
 in its first hitch, so that when this is pulled 
 tight it does not slip before the second hitch 
 is made and drawn up. For ligatures that 
 are transfixed I use the Staffordshire knot. 
 
 For the first dressing of the wound I use 
 nothing but the absorbent cotton- wool intro- ^"*' ^s-Doubie-hitch Knot, 
 duced by Mr. Sampson Gamgee, and I know of no greater addi- 
 tion to our means of treating wounds than this simple material. 
 It is made up into pads of different sizes and shapes, averaging 
 about five inches square, and from one and a half to two inches 
 thick. Two or three of these are placed over the wound and 
 are secured in their places by two or three narrow straps of 
 sticking-plaster, the whole dressing being covered by a cotton 
 binder round the patient's waist, and this is fastened with safety- 
 pins. This dressing is rarely touched before the fourth day, 
 when fresh padding is adjusted. On the sixth or seventh day 
 I remove every alternate stitch and the rest are removed on the 
 day following, and it is quite an unusual thing to find the wound 
 otherwise than completely and permanently united. 
 
 In the Medical Times of March, 1874, Dr. S. G. Stephens, of 
 Eio Bueno, Valdivia, Chili, gives an account of an "■ Ovariotomy 
 under Difficulties," which is such a splendid instance of surgical 
 pluck, crowned, fortunately, with success, that I wish to do what 
 
 ' A great deal of fusa has recently been made concerning some experiments per- 
 formed by Mr. Spencer Wells on rabbits and other animals, relative to the inclusion of 
 the peritoneum in the stitches, and it is claimed by Mr. Wells that by these experiments 
 hundreds of women's lives have been saved. As it is a surgical rule to secure the 
 CO aptation of all divided structures, as it never was doubted that the peritoneum was 
 an exception to this rule, Mr. Spencer Wells' experiments were altogether needless, 
 and contributed nothing whatever to the advance of abdominal surgery. In many 
 instances I have been obliged to leave the peritoneum out of the stitches, and I never 
 saw that this exclusion made the least difference to the patient's recovery.
 
 292 DISEASES OF THE OVAEIES. 
 
 little I can to commemorate the hero, and therefore I give his 
 account here in full : 
 
 "We had to send to Valdivia for chloroform — four days' 
 journey. In the meantime I occupied myself in preparing the 
 patient, in considering with what instruments I was to perform 
 the operation, and selecting and instructing my assistants. The 
 instruments were a trocar made from a piece of colhuihue ' 
 about ten inches long, hollowed out, and sharpened to a point at 
 one end, and at the other connected with a piece of india-rubber 
 tubing from an enema syringe ; the instruments from a ' Char- 
 riere ' pocket-case, and a pair of craniotomy forceps. The as- 
 sistants were a Catholic missionary, two Indians, and a half- 
 blood. The ligature was made of raw-hide, with two pieces of 
 wood fastened at the ends, in order that more power could be 
 used in pulling it tight, and at the time of using it was to be 
 dipped in warm neatsfoot oil. 
 
 ' ' The pedicle was rather long, but flat ; the raw-hide ligature 
 was applied to it, and tightened by means of the two pieces of 
 wood pulled by the two assistants on each side of the body until 
 it was almost buried in the parts, and then made fast with two 
 lasso-knots,^ the ends cut off, and the whole dropped into the 
 cavity. The cavity was mopped out with cotton-wool, and the 
 wound closed with fine iron-wire sutures, pushed through from 
 within outward and twisted, and a superficial continuous su- 
 ture of silk. Water-dressing was next applied, and a warmed 
 bayeta flannel roller passed twice round the body. Conscious- 
 ness returned before I could get her off the table, owing to the 
 priest not attending to the chloroform, being too occupied and 
 astonished at my movements ; in fact, throughout the whole 
 proceedings I had constantly to attend to the pulse. Great 
 exhaustion followed ; and I had first to administer warm wine- 
 and-water, and afterward warm whiskey-and-water, apply fric- 
 tion to the extremities, until, finally, at five o'clock in the after- 
 noon, she had improved very much, with a pulse at 115, and 
 the surface warm and moist. My thermometer was broken, 
 so I could not note the temperature. I remained in the neigh- 
 borhood twelve days to attend to her, during which time she 
 Avent on well, with the exception of a little vomiting the day 
 after the operation, owing to the husband giving her warm 
 lamb's blood without my knowledge. The first pair of sutures 
 were removed on January 28th, and so on, day by day, one or 
 
 ' A species of bamboo. 
 
 ' One on each side — i. e.. one tied first, and then the ends carried round to the 
 opposite side ; a slit made in one end. and the other cut in the form of a knob, which 
 passes through it. thus preventing .slack jning through swelling.
 
 OVARIOTOMY. 293 
 
 more was removed, until the ninth, or middle one, was taken 
 out. 
 
 " ISTever having seen the operation, nor read any special work 
 on the subject, I had nothing to direct me but the short account 
 given in the last edition of Dr. Tanner's ' Practice of Medicine.' " 
 
 Occasionally we are called upon to deal with an ovarian 
 tumor in a woman who is pregnant — a complication which may 
 or may not be discovered before the operation. Some years ago 
 the question of the propriety of removing an ovarian tumor in a 
 pregnant woman was discussed before one of the medical socie- 
 ties, and various opinions were given. By some obstetric physi- 
 cians the opinion was expressed that it would be better to induce 
 premature labor, and that after the patient had recovered from 
 this, we should perform ovariotomy. Mr. Spencer Wells and 
 myself, on the other hand, contended that it would be much 
 better to perform ovariotomy, and leave the pregnancy alone, 
 and this plan has now become the accepted practice. At that 
 time Mr. Wells had operated upon ten pregnant women, and nine 
 of these cases were successful. I do not know what his experi- 
 ence may have been since, and I have not found any record of 
 the experience of any one else upon this subject ; but since the 
 discussion I have operated upon ten pregnant women with uni- 
 form success. Before that time I had only operated in one such 
 case. The result was fatal, and was undoubtedly due to the use 
 of the clamp, for the cause of death was gangrene of the pedicle. 
 I do not now think pregnancy offers any bar to the operation. 
 In all of my cases I have been able to recognize the pregnancy 
 before I opened the abdomen ; but I can easily imagine that it 
 might occur to the most experienced surgeon to operate on a 
 woman in whom he had not previously recognized the existence 
 of the complication. Indeed, Mr. Wells tells us of a case in 
 which he punctured a pregnant uterus with a trocar, having 
 mistaken it for a cyst. He opened the uterus, emptied it of its 
 contents, and the patient recovered.* This is one of the compli- 
 cations, therefore, to be especially borne in mind. The usual 
 color and appearance of an ovarian cyst is as a rule sufficiently 
 characteristic to make it easily recognizable from a pregnant 
 uterus ; yet I can easily imagine circumstances such as Mr. 
 Wells encountered, that would lead to such a mistake ; and 
 should this misfortune happen, the bold proceeding he followed 
 would certainly be the best practice. 
 
 We not unfrequently find tumors of the uterus associated 
 
 ' A similar accident happened to Dr. Byford, of Chicajro, and he successfully fol- 
 lowed out the same practice as did Mr. Wells. (American Journal of Obstetrics, 
 January, 1879.)
 
 294 DISEASES OF THE OVARIES. 
 
 with cystic disease of the ovaries. It has happened to me very 
 frequently to find a very large part of the mass which I believed 
 to be entirely ovarian formed of a uterine myoma associated 
 with an ovarian cystoma. Under such circumstances the prac- 
 tice now universally adopted is to remove the ovarian tumor 
 and leave the uterine mass alone, but formerly it was regarded 
 as the correct practice to remove both. Further on I shall deal 
 again with this important subject, but here I will say it is my 
 uniform practice now, when I find a uterine myoma in existence 
 as well as an ovarian tumor, to remove both ovaries and tubes, 
 as in this way we can arrest the growth of the tumor we cannot 
 remove ; indeed, in some of my cases the tumor has entirely 
 disappeared. 
 
 One of the most interesting additions to our advances in ab- 
 dominal surgery is that originally derived from an operation 
 performed by Dr. Wiltshire, who removed an ovarian tumor 
 from a woman suffering from symptoms of the utmost gravity, 
 due to peritonitis and gangrene of the tumor. The case is de- 
 scribed in the "Transactions of the Pathological Society" for 
 1868, the operation having been performed in May of that year. 
 
 Rapid increase of the tumor had taken place, and there were 
 symptoms of the most urgent kind present. Vomiting had been 
 incessant for three days, when, after unusual exertion, rapid 
 enlargement of the tumor had begun. The pulse was quick and 
 feeble, the extremities blue, and the patient's general condition 
 one of collapse. 
 
 The extreme tension of the abdominal parietes was shown 
 by the way in which the tumor shot up into the wound directly 
 the incision reached the peritoneal cavity ; it had also rotated. 
 Blood escaped on puncture, and at one place the cyst wall gave 
 way when touched, owing to extreme thinness. The pedicle 
 was rotten, and the right cornua of the uterus had to be trans- 
 fixed and tied to arrest hemorrhage. 
 
 The tumor proved to be of the right ovary and multilocular, 
 the loculi being distended with blood. It had rotated on its ped- 
 icle four days before the operation, strangulation ensuing. The 
 twist was from right to left, and appeared to have given two 
 turns. The pedicle was quite small and short. 
 
 I think sufficient praise can hardly be given to Dr. Wiltshire 
 for his courage in performing the operation under such urgent 
 conditions, and it is not too much to say that to his success in 
 this case we owe a new departure in the practice of abdominal 
 surgery by which operations under acute symptoms are under- 
 taken, and, apparently, with results as satisfactory as those 
 obtained in cases free from emergency.
 
 OVARIOTOMY. 295 
 
 This remarkable axial rotation is an incident in the life-his- 
 tory of ovarian tumors, which has not yet received as much 
 attention as either its importance or its frequency deserves, 
 and, so far as I knov^^, no perfectly satisfactory explanation of 
 the method of its occurrence has been given. 
 
 So far as I can find, the first notice of the incident is made 
 by the same author who has written most about it, Hofrath Pro- 
 fessor Carl Rokitansky, who describes it in his " Handbuch der 
 Pathologischen Anatomic" (vol. i.) in 1841. There the descrip- 
 tion is not full, but it is certain that he had then seen it, and in 
 his future papers he tells more about it than does any other 
 author ; indeed, most other writers have taken their descriptions 
 from him with more or less acknowledgment. 
 
 I have found reference to a note of a paper by him in the 
 Allgemeine Wien Medizinisclie Zeitschrift for 1840, but have not 
 been able to find the original paper. Possibly the note in ques- 
 tion is a misprint, though the title is given in full, " Ueber Ab- 
 schnerung der Tuben und Ovarien und ueber Strangulation der 
 Letzeren durch Achsendrehung." 
 
 Rokitansky has also written very full papers in the Allge- 
 meine Wiener Medizinisclie Zeitung, 18G0 ; in the Zeitschrift 
 der K. K. Gesellschaft der Aerzte in Wien, 1865; "Ueber der 
 Strangulation von Ovarialtumoren durch Achsendrehung." 
 
 Dr. Van Buren narrates two cases in which he noticed the 
 twisting of the pedicle of an ovarian tumor, in the New York 
 Journal of Medicine, 1850 and 1851. 
 
 In the first the tumor was on the left side, but the direction 
 of the twist is not given. The twist had not strangulated the 
 tumor, and did not hasten the ovariotomy, which was success- 
 ful. 
 
 The second case was one in which acute peritonitis was diag- 
 nosed on August 28th, and the patient died on September 8th. 
 On post-mortem examination the tumor was found very dark in 
 color, almost black. It was a tumor of the right ovary, but the 
 direction of the twist is not stated. " The twisting of the pedi- 
 cle interrupted entirely the circulation, the tumor thus became 
 engorged with blood, thence peritonitis, followed by enteritis, 
 causing death." The tumor had made one and a half revolu- 
 tions only, the pedicle being short. 
 
 Dr. Patruban (Oesterreiches Zeitschrift fiir practische Heil- 
 kunde, 1855) publishes a case where the torsion produced rapidly 
 fatal intracystic hemorrhage. 
 
 Dr. Crome, of Brooklyn {American Medical Monthly, 1861), 
 had a case where the strangulation occurred twenty-four hours 
 before labor in a small tumor, the patient dying of peritonitis
 
 296 DISEASES OF THE OVARIES. 
 
 on the fifth day. The accident was indicated by the access of 
 agonizing pain in the left side. Tlie cyst was found ruptured 
 and in a state of gangrene. 
 
 In his book on " Diseases of the Ovaries," Mr. Spencer Wells 
 mentions that, during his first five hundred cases, he found the 
 pedicle twisted in about twelve cases, but no mention is made of 
 any of the tumors being consequently gangrenous, or that the 
 operation was thereby hastened. 
 
 In the Archiv fiir Gynecologie for 1878, Dr. Yeit, of Berlin, 
 quoting Schroeder, says, that in his 94 cases of ovariotomy, 
 axial rotation was observed 13 times, and Olshausen is of opin- 
 ion that the tumors are generally non-adherent. 
 
 Dr. St. John Edwards, of Malta, has published a case in the 
 Lancet, of October, 1861, in which he had recognized an ovarian 
 tumor during the lady's first pregnancy. Her second labor oc- 
 curred prematurely, sudden abdominal pain supervened on the 
 second day after, and she died on the fourth. The tumor was 
 found to be of a livid purple color, with patches of extravasated 
 blood, and rents in its walls. The right ovary was flattened out 
 on its under aspect (so that it must have been a parovarian cyst). 
 The pedicle was two inches long, and had been twisted one and 
 a half times round. It was intensely congested, and the ovary 
 was full of dark extravasated blood (closely resembling one of 
 my own cases). There was no peritonitis, and the tumor was 
 absolutely free from adhesions. The contents of the sac were 
 claret-like. He attributes the twisting to the expulsive action 
 of the uterus, though the accession of pain was not till about 
 forty-eight hours after labor. 
 
 In the Edinburgh Medical Journal I published the following 
 case, wiiich I desire to reproduce here, as it was the first of my 
 experience of this remarkable accident : 
 
 On August 18, 1868, I was called in consultation by my 
 
 friend, Mr. Lorraine, of Wakefield, to see Mrs. C , aged 
 
 forty-eight, wdio was suffering from a strangulated femoral 
 hernia. I found the tumor of small size, that the symptoms 
 had existed only two days, and that it was irreducible by the 
 taxis under chloroform. I suggested a full dose of belladonna 
 and a delay of six hours. At the end of that period I again 
 tried the taxis under chloroform, but without being able to re- 
 duce the hernia, so I at once performed Gay's operations, divided 
 Gimbernat's ligament freely, and without any trouble succeeded 
 in returning the bowel. 
 
 At 7.30 on the morning of the 19th she w-as much relieved, 
 free from pain, and the vomiting had quite ceased-. Opium was
 
 OVARIOTOMY. 297 
 
 administered freely, and iced brandy-and-water or Moselle ad 
 libitum. 
 
 August 20th, 8 A.M.— The abdomen was slightly tympanitic, 
 and the pulse about liO, the patient being free from pain and 
 sickness. 8 p.m. — Tympanitis increased ; ordered a turpentine 
 stupe. 
 
 August 21st, 8 A.M. — Tympanitis so extreme that I enter- 
 tained the idea of puncturing the intestines. Temperature in 
 axilla, 101.6°; no pain or sickness, and she takes beef -tea and 
 stimulants freely; face very anxious in expression. 10 p.m.— Mr. 
 Lorraine had seen her in the afternoon, and reported that she 
 was somewhat better. When we met we found that the disten- 
 tion was much less ; there was no pain and no narcotism, as the 
 opium had been intermitted ; rectum examined per vaginam, 
 and found quite empty; temperature in axilla, 101°. 
 
 August 22d. — In the forenoon she had two moderately sized 
 and very offensive stools ; in the afternoon she was seen by my 
 friend, Mr. Kemp (in whose practice the case occurred), who no- 
 ticed, and remarked to me afterward, that the breath had the 
 hay odor. At 10 p.m. I saw her with Mr. Lorraine, and we both 
 noticed the musty smell of the breath. She was sinking then, 
 and died at 8 a.m. on the morning of the 23d. 
 
 Twelve hours after death I made a post-mortem examination, 
 with the kind assistance of Mr. Lorraine and Mr. J. Kemp. 
 The wound made to relieve the strangulation had healed by first 
 intention. On opening the abdomen I found the small intes- 
 tines much distended Avith flatus. The sac of the hernia was 
 empty and uninjured. On separating the intestines a black 
 gangrenous mass was observed lying in the concavity of the 
 right ilium. On passing my hand round it I discovered that it 
 was a small ovarian tumor, consisting of two equal-sized cysts, 
 one of which was totally gangrenous, and so soft as to break up 
 with the most gentle handling, and discharge into the cavity a 
 quantity of dark fetid serum ; the other cyst was partially gan- 
 grenous. The tumor measured about eleven inches long and 
 four inches in its greatest diameter, and it had a constriction 
 between the two cysts. Its base was slightly glued to the brim 
 of the pelvis ; but, with this exception, there was no peritonitis. 
 The tumor lay across the transverse diameter of the pelvis, the 
 left end being buried in the pelvis, while the right lay over the 
 brim on to the ilium. It was the right-hand cyst which was 
 totally gangrenous. 
 
 When I passed my hand down the pedicle I found that it was 
 long and thin, and twisted on itself, feeling more like an injected 
 umbilical cord than anything else with which I am acquainted.
 
 298 DISEASES OF THE OVARIES. 
 
 I remarked to my colleagues that the pedicle was twisted, 
 and, keeping it in my left hand, with my right I slowly un- 
 twisted it, by rotating the tumor until the pedicle was straight. 
 To do this, I had to alter my grasp of the tumor nine times ; 
 that is, the pedicle had been twisted by four and a half revolu- 
 tions of the tumor. It was the right ovary which was diseased 
 (and the twisting was from within outward toward the right 
 side, as far as my recollection now serves me). 
 
 Concerning this case, I have ever since had a suspicion that 
 my operation for hernia was an unnecessary one, and that all 
 the symptoms were really due to the gangrenous tumor. If this 
 were really so, I have the consolation that I did my patient no 
 harm. 
 
 When this case came under my care I had never heard of 
 the accident, indeed it occurred nearly twelve years ago, and 
 my experience of ovarian tumors was somewhat more limited 
 than it is now. It made a deep impression on me, however, and 
 I resolved if ever I met with such symptoms in another woman, 
 and could discover the presence of a tumor, I should not hesitate 
 to attempt its removal. This determination I have been able to 
 carry into effect on nine occasions with perfectly successful 
 results. Of course, I cannot but regret that I did not recognize 
 the existence of this tumor when I had the patient under chloro- 
 form, as I think I could do now with my larger experience in 
 abdominal surgery, though, perhaps, my youth and inexperience 
 at the time form a barely sufficient apology. 
 
 The next case I find on record is one published by Dr. Barnes 
 in St. Thomas's Hospital Beports for 1870, where Mr. Spencer 
 Wells, Dr. Tyler Smith, and Dr. Oldham had all recognized the 
 presence of an ovarian tumor. Dr. Barnes saw her on August 
 26th, and on September 2d, when the diagnosis of pregnancy, in 
 addition, was made. On the 25th there were all the indications 
 of mischief in the cyst, and Dr. Barnes discussed the question, 
 ''Has the extra-uterine cyst ruptured?" On that day a prema- 
 ture foetus was expelled, and she lingered on till October 4th 
 without any attempt at surgical interference. 
 
 At the post-mortem "a cyst came into view, dark-colored, 
 stained with blood in several points, having extravasated blood 
 clotted in its walls. In places it was found very fragile ; it had 
 twisted twice axially from right to left during life." 
 
 I do not think there can be a doubt that if this case had been 
 operated upon, as it might have been, seeing the tumor had been 
 recognized, the patient would have recovered. 
 
 A still more curious case is related by Dr. Barnes in the
 
 OVARIOTOMY. 299 
 
 same paper, where the symptoms of strangulation were taken 
 for those of labor, and where, on post-mortem examination, he 
 says he found an ovarian tumor entirely free from adhesions, 
 with its pedicle twisted twice into a rope, the appearances of 
 gangrene being conclusive. Such a case would be just such a 
 one in which ovariotomy would be, and has been in my hands, 
 successful. 
 
 At a meeting of the Dublin Pathological Society, December 
 4, 1879, Dr. Kidd showed the preparation from a woman whom 
 he had had under his care in the .Coombe Hospital, and who 
 had died under circumstances which clearly pointed to some- 
 thing wrong in a tumor which had been recognized some 
 months before. The preparation was that of an uncomplicated 
 ovarian tumor, with twisted pedicle and consequent gangrene. 
 "There was a complete turn upon the pedicle ; this had strangu- 
 lated the tumor, and thus gave rise to the black appearance, 
 and the woman died from irritative fever, produced by strangu- 
 lation and sphacelation of the morbid growth." This is another 
 case where I think there is cause for regret that an attempt at 
 removing the tumor was not made. From the experience I am 
 about to give of my own practice, I think there can be little 
 doubt that the rule will be established that if the existence of 
 an ovarian tumor has been, or can be recognized, and symptoms 
 should set in which are of a serious kind, and can be referred 
 to strangulation of that tumor, an exploratory incision should 
 be made, and the tumor removed if possible, especially if it be 
 found to be the seat of the mischief. 
 
 During 1879 I had the remarkable occurrence in my practice 
 of three cases of gangrene of ovarian or parovarian tumors, due 
 to axial rotation. 
 
 The first case was sent to me by Dr. Faussett, of Tamworth. 
 She was forty-six years of age, her last confinement was four 
 years before, and her menstruation was normal. I saw her first 
 in March last on account of a small tumor, which I diagnosed 
 to be monocystic, and probably parovarian. I advised her to 
 defer any operation till it was larger. She returned on June 9th 
 with the tumor greatly enlarged, and suffering from intense 
 abdominal pain. Her face had a peculiar anxious expression, 
 and her temperature rose to 39° C. at night. I therefore recom- 
 mended the immediate removal of the tumor. On opening the 
 abdomen I found the cyst of a black pearly color, universally 
 adherent by recent lymph, its contents quite black, and its walls 
 black, gangrenous, and in places quite rotten. The pedicle was 
 twisted three or four times, and at the point of maximum con- 
 striction it was only as thick as an artist's pencil. I tied it just
 
 300 DISEASES OF THE OVARIES. 
 
 below this point. After the operation she had no pain, the 
 temperature never rose above 37° C, and she made an uninter- 
 rupted recovery. The right ovary was involved in the gangrene, 
 but it was free from the tumor. The rotation had occurred 
 from within outward to the right. The operation was per- 
 formed without any of the Listerian antiseptic precautions. 
 
 The second case occurred in a patient from Sheffield, placed 
 under my care by my colleague, Dr. Edginton. She was thirty 
 years of age, had been married ten years, but had never been 
 pregnant. 
 
 She had noticed a gradual increase in size for nine months 
 previous to my seeing her. Sudden and violent pain in the 
 abdomen occurred on the 4th of November, followed by inces- 
 sant sickness. When I saw her on the 11th the diagnosis of an 
 ovarian tumor was simple, and her anxious appearance, the 
 green sickness, feeble pulse, and the intense pain, all pointed 
 to the probability of strangulation of the tumor. I therefore 
 admitted her at once to the hospital, and removed the tumor 
 next day. It was found to be uniformly adherent to all the tis- 
 sues in contact with it, the adhesions being recent and easily 
 overcome, but they gave a great deal of trouble from free and 
 abundant hemorrhage. This was controlled chiefly by the 
 application of solid j^erchloride of iron to the bleeding points. 
 The tumor itself was a multilocular cyst of the right ovary, of 
 a uniformly dark purple color, extremely friable, having large 
 extravasations of blood in the walls, and especially at the base, 
 close to the pedicle. The pedicle was very short, and was 
 twisted twice completely round, from within outward and to 
 the right. The operation was performed with complete antisep- 
 tic precautions, but the temperature and pulse curves show that 
 she made anything but an antiseptic recovery. The pedicle 
 was secured by the Staffordshire knot. She left the hospital on 
 December 14, 1879. 
 
 The next case occurred immediately after that just narrated. 
 She was thirty-six years of age, had had children, the last four 
 years ago. She had not menstruated for seventeen weeks, but 
 had noticed an increase of size so rapid that it could not be ex- 
 plained by ordinary pregnancy. I saw her for the first time on 
 November 10th at the out-patient department, and though the 
 diagnosis was difficult on account of the patient being very fat, 
 I made out early pregnancy and an ovarian tumor. 
 
 She came back on November 23d complaining of intense 
 abdominal pain, which had come on suddenly two days before, 
 followed by incessant sickness. She looked very ill, and vom- 
 ited green matter while in the consulting-room. I at once sent
 
 OVARIOTOMY. 301 
 
 her into the hospital and called an emergency consultation with 
 my colleague, Dr. Savage. He agreed with me that it was a 
 case of pregnancy, with a strangulated cyst, the only argument 
 against this view being the apparent absurdity of my having 
 two such cases in the hospital at the same time, and the likeli- 
 hood that our recent experience should lead us into too ready a 
 diagnosis. However, we stuck to our view, and agreed upon 
 immediate operation. This I performed, and found the case to 
 be exactly as I had diagnosed. The uterus was occupied by a 
 pregnancy of about the fourth month, and the tumor was a par- 
 ovarian cyst of the right side, of a pearly black lustre, the ovary 
 lying on its front in the line of incision, at least ten times as 
 large as an ordinary ovary, being four inches long and two 
 broad, the enlargement being due entirely to extravasation of 
 blood in its tissue. The Fallopian tube stretched over about a 
 third of the circumference of the tumor, running down toward 
 its twisted pedicle, of which it formed part. In the wall of the 
 tumor, and especially at its base, were effusions of blood. The 
 contents of the tumor were straw-colored, but viscid. The 
 tumor had made three complete revolutions from within out- 
 ward and to the right side. There were no adhesions, and the 
 operation presented no difficulty, and it was carried out with 
 complete Listerian antiseptic precautions. She made a better 
 recovery than the second case, but not so good as the first, to 
 which it really had a very close resemblance. No symptoms of 
 miscarriage showed themselves. She left the hospital on De- 
 cember 21st, and her pregnancy was satisfactorily terminated. 
 
 One feature which was characteristic of all three of these 
 cases, and which I have omitted to mention in connection with 
 the second, is that the abdomen undergoes a very rapid and un- 
 usual increase in size for a few days before, or coincident with, 
 the access of the violent pain. In two it was noticed to have 
 occurred to a marked degree before pain was felt, and this we 
 may easily believe to be the stage of strangulation productive 
 of oedema and precedent to that of gangrene. This points to 
 the conclusion that the rotation is gradual. I have had six other 
 cases in all of which the leading features were identical with 
 those narrated. 
 
 The symptoms recorded in all these cases are closely alike. 
 The chief feature is the sudden accession of severe abdominal 
 pain and tenderness, followed immediately by vomiting, which 
 soon becomes green. The pulse rises, but the temperature does 
 not always do so. These symptoms in the recognized presence 
 of an abdominal tumor which may be ovarian, should lead at 
 once to abdominal section, and they would do so in my practice,
 
 302 DISEASES OF THE OVARIES. 
 
 whether the tumor were ovarian or not, if there seemed to be 
 any probability of its being possible to remove it. 
 
 As to the mechanism by which this singular rotation is pro- 
 duced, we may at once dismiss any explanation which attributes 
 it to the condition of the tumors themselves, for we find it occur- 
 ring in tumors of all kinds, large, small, smooth, and globular, 
 multicystic and irregular, parovarian, ovarian, dermoid, and 
 solid fibrous tumors, the only intrinsic conditions of the tumors 
 being that they should be free to move, and have pedicles capa- 
 ble of being twisted. 
 
 Unfortunately, in the majority, or at least in a very large 
 number, of the cases, the direction of the twist is not clearly 
 stated, or not given at all, nor is the side on which the tumor 
 grew clearly given. 
 
 Of the cases narrated by Rokitansky, the great majority, 
 about four-fifths, were tumors of the right side, and in a still 
 larger proportion the twist was from the left to the right side — 
 that is, taking the vertebral column as the starting-point, the 
 twist travelled to the left side, and then forward and over to the 
 right, that being w^liat I read as his " und ebenso kommt die 
 Drehung nach aussen weitans haufiger vor, als jene nach in- 
 nen," though it is by no means certain that my rendering is cor- 
 rect. 
 
 Certainly, in all of my own cases the tumor was on the right 
 side, and the twisting in all those operated upon was as I have 
 just described, and in the first case I have given my recollection 
 as that it was in this direction also. It is not recorded so in my 
 notes, however, and my memory may be in error, though I 
 think it is likely to be correct, as the case made a more profound 
 impression on my mind than, perhaps, any other incident in my 
 surgical experience. 
 
 If we had exact statements on these points for a large number 
 of cases, I think we might arrive at some conclusion as to the 
 cause of the rotation. 
 
 In a few of the isolated cases explanations are given which 
 seemed more or less possible to the narrators, but they do not 
 bear the examination of extended experience. To two of these 
 I have already alluded, and only a third requires to be men- 
 tioned. Dr. Barnes hazards the explanation that " the tumor 
 being free from adhesions, and tolerably firm, may roll over on 
 its axis. This may happen from the enlargement of the uterus 
 tilting it over, or from over-exertion, when, one part of the 
 tumor being more pressed upon than the opposite part, it rolls 
 over." The part of this explanation which applies to cases where 
 the rotation occurs in association with a pregnant, uterus applies
 
 OYARTOTOMT. 303 
 
 only to a small number of the cases, even if it were sufficient, 
 which I do not think it is, and therefore may be dismissed. The 
 rest of the explanation simply amounts to a repetition of the fact 
 that this singular phenomenon does occur, and is no explanation 
 at all. 
 
 The only reasonable effort to explain the incident has been 
 made by Klob, who has made some experiments, from which he 
 concludes that it is the alternate filling and evacuation of the 
 bladder which rotates the tumor. I have not been able to find 
 the original paper, and am, therefore, unable to criticise the basis 
 of his opinion, but on a jyriori grounds I think there may be 
 something in his idea. But before I knew of this explanation, 
 and entirely from my own cases, I had come to the conclusion 
 that it was the alternant filling and emptying of the rectum 
 which caused the rotation, and it is possible enough that the 
 bladder may help. That the bladder alone should do it is, I 
 think, unlikely, for being central its influence \vould be, in all 
 probability, neutral. If it were the rectum, then this force act- 
 ing on the left side of the point of rest, the vertebral column, 
 would inevitably push the tumor in the direction in which, in at 
 least nine out of ten of my cases, the movement took place ; 
 and it would certainly act more readily on right-side tumors than 
 on those of the left side, for the former are anchored so that 
 the pushing force of the rectum will be in the requisite oblique 
 direction, in the plane of a screw, and very nearly at right an- 
 gles to the axis of movement. 
 
 If I might venture to apply a dynamical illustration to path- 
 ology, I would say that an ovarian tumor growing on the right 
 side with a free pedicle, and resting, therefore, with its axis in- 
 clined toward the top of the ninth or tenth rib on the left side, 
 would be in the condition of a body having freedom of the first 
 order — that is, free to rotate about a fixed axis, but not to slide 
 along it. To such a body a screw, in the form of a wedge, would 
 be applied by the rectum in the most favorable of all directions, 
 in a direction obliquely from above downward, across the axis of 
 freedom and below the equator of the moving body. Every 
 piece of faeces which passed into the rectum, especially in the re- 
 cumbent position of the patient, would act as a wedge to drive 
 the tumor round. In obedience to the dynamic law, that by a 
 successive repetition of the process an indefinite quantity of en- 
 ergy may be produced, however small the initial force may be, we 
 have at once the explanation of the phenomena of many of these 
 cases, notably of that published by Mr. Thornton. We have, in 
 fact, this process of rotation going on slowly until the point of 
 strangulation has arrived, when the sudden access of pain for
 
 304 DISEASES OF THE OVAKIES. 
 
 the first time indicates that something has gone wrong. For the 
 bladder a similar wedge-like influence may be claimed, but from 
 its want of obliquity, it is not likely to be so powerful an agent 
 in the production of rotation. Both rectum and bladder would 
 act, however, in the same direction, and if it be found on further 
 investigation that the tumors are mostly those of the right side, 
 and are generally twisted in the direction in which mine were, I 
 think we may accept the rectum as the chief factor. 
 
 That this rotation may occur suddenly, that is to say, that an 
 ovarian tumor may be twisted rapidly round two or three times 
 in a few minutes or hours, is inconceivable. 
 
 Rokitansky publishes (1SG5, loc. cit.) the post-mortem ac- 
 counts of fifty-eight cases of ovarian tumor in a period of four 
 years, and in eight of these rotation of the tumor had occurred, 
 but in four only did it seem to have given rise to strangulation 
 and death. Rotation is, therefore, frequent, as Rokitansky says, 
 occurring in about twelve per cent, of all cases, and in about six 
 per cent, of all cases producing death. My own proportion is 
 not nearly so high, my first hundred ovariotomies including 
 only one of my cases, and in the practice of other ovariotomists 
 we have not as yet heard much of gangrene from rotation. 
 
 The greater part of what I have just said on this interestingsub- 
 ject is taken from a paper which was read before the Obstetrical 
 Society of London last year. In the discussion which followed, 
 my theory of the cause of axial rotation received very material 
 confirmation from Mr. Alban Doran, who said that it accorded 
 with some of his own convictions grounded on experiments he 
 had made in the post-mortem room of the Samaritan Hospital 
 when examining cases of ovarian disease that had proved fatal 
 before any operation could be performed. Supposing that a large 
 tumor with an irregular surface lay to the right of the rectum, 
 an accumulation of fseces might press upon the pelvic portion of 
 the growth in such a manner as to push the whole tumor about 
 a quarter of a turn round its vertical axis. Should the pedicle 
 be very long, or short, yet inelastic, it would remain twisted after 
 this pressure was removed, and might become still more twisted 
 after it was reapplied. Should the pedicle be short and elastic, 
 the tumor would slip back to its normal position every time that 
 the pressure was removed ; only this pressure might be applied so 
 long that the temporary torsion might involve damage to the 
 vessels of the pedicle, producing all the bad effects of permanent 
 and complete torsion after the pedicle has become untwisted. 
 In examining the body of a patient who died in Mr. :f<:nowsley 
 Thornton's ward last December he found a large ovarian tumor 
 pressed upon to the left side, inferiorly, by the rectum, which
 
 OVARIOTOMY. 305 
 
 was slightly distended owing to a cancerous stricture. A little 
 artificial distention of the intestine caused it to press against the 
 tumor so as to push its left side backward, stretching and twist- 
 ing the pedicle. In examining this pedicle he found that it was 
 not twisted, but that its veins were partially plugged, in all prob- 
 ability from the effects of intermittent pressure through fre- 
 quent extreme distention of the obstructed rectum. 
 
 Mr. Wells suggested that the rotation was little more than an 
 accident, but an accident of such frequent occurrence must have 
 some kind of uniform cause ; and if it be true generally, as it cer- 
 tainly was in Rokitansky's observations and in my own, that the 
 great majority of the tumors twisted were right-sided tumors, and 
 that they were twisted in one specific direction, it is clear that 
 some special mechanism must be concerned in the process of ro- 
 tation. The facts given by Mr. Alban Doran are emphatically in 
 favor of the theory I have advanced, and, doubtless, if Mr. Doran 
 continues his observations,' some valuable results will be arrived 
 at. If a left-sided tumor could be found rotated from within 
 outward and over to the left, in a case where the rectum was on 
 the right side, I should regard my hypothesis as proved. 
 
 Rokitansky says that, as one of the results of this rotation 
 and strangulation of ovarian tumors, we may get involution and 
 wasting of the growth, so that in many cases they may diminish 
 and disappear ; and Mr. "Wells, quoting Rokitansky, seems to 
 agree with him. 
 
 There is reason to believe that sometimes this axial rotation 
 succeeds in destroying the pedicle altogether, and separating the 
 tumor from its connection, one might imagine a tumor possibly 
 being quite cured in this way. Dr. Peaslee {American Journal 
 of Obstetrics, 1878) mentions a case of an ovarian tumor detached 
 from its pedicle, in which, from the history, I believe it likely 
 that the detachment was effected by axial rotation. Dr. Peaslee 
 says : ''After the tumor had grown about two years, it ceased 
 growing entirely for six or eight years, then it began to grow 
 again. It was very singular that he could find no connection 
 between the first cessation of growth and the second accession. 
 It was thought by her friends that she had hernia, for there was 
 great suffering, referable to the inguinal region. It kept her in 
 bed some time. After she got up, the tumor grew no more. 
 At the operation the omentum was found to be quite exten- 
 sively adherent, and there was near it an artery of peculiar 
 development, about the size of the brachial artery, which 
 divided into a great many branches. Upon putting his hand 
 into the cavity, he found that he could run it all around the 
 tumor ; he found no pedicle whatever ; all the attachment it had 
 20
 
 306 DISEASES OF THE OVAEIES. 
 
 was that referred to above. He then proceeded to ligate the 
 vessels and removed the tumor. He found it to present all the 
 characteristics of an ovarian cyst; there could be no doubt as 
 to what it was. There was a notch in the broad ligament, show- 
 ing that, at the time of the attack, there had been a pedicle. It 
 had become twisted around and around, so that the circulation 
 had been cut off, and it ceased growing. It had been nour- 
 ished, no doubt, from contact, from which circumstance this 
 series of larger vessels had sprung up, the vessels being larger 
 in proportion as necessity required." 
 
 Besides the acute symptoms which are induced by the stran- 
 gulation of an ovarian or parovarian tumor, we may have a 
 condition of equal severity arising from peritonitis or from sup- 
 puration of the cyst. I have on seven occasions been obliged to 
 remove tumors at a very few hours' notice, when summoned 
 to patients suffering from acute peritonitis. Of these seven, 
 six made excellent recoveries, all the symptoms disappearing 
 in a few hours after the operation. The fourth case was one 
 which occurred in my early practice, when I used the clamp, 
 and from this cause the patient died. From the results obtained 
 by the immediate removal of tumors when there is peritonitis, 
 in the hands of Dr. Keith, Mr. Spencer Wells, Mr. Pridgin Teale, 
 of Leeds, and others, the rule has become quite established to 
 operate without delay when there is this complication. f\lj 
 
 Suppuration of a tumor is not unf requently met with. "^ Usu- 
 ally it is the result of tapping, but I have seen it occur without 
 any ascertainable cause. The symptoms are not generally so 
 pronounced as they are in peritonitis, but they are always suffi- 
 ciently severe to attract attention, and to give rise to a suspi- 
 cion of the actual state of matters. When there is reason to 
 believe that so grave an accident has occurred, immediate re- 
 moval of the tumor is the correct practice, more particularly if 
 the symptoms have occurred after tapping. In such cases, of 
 course, the cleansing of the peritoneum must, if possible, be made 
 with even greater care than in any others, and I think that 
 probably in cases where there is pus in the peritoneum, drain- 
 age after the plan of Koeberle and Keith will conduce to the 
 recovery of the patient. 
 
 Dr. Keith was the first to set the example of removing an 
 ovarian tumor under these desperate circumstances. His first 
 case was in December, 1864, and was successful. He tells us 
 {Edinburgh MedicalJournal, 1875) : " Since then I have ten times 
 met with cases of acute suppurating cysts, besides two chronic 
 cases. In all of these, save one, the chance of ovariotomy was 
 given, however hopeless-looking the case might be."
 
 OVAKIOTOMY. 307 
 
 After the performance of an ovariotomy, and after the pa- 
 tient has recovered from the effects of the anaesthetic, the first 
 symptom we have to deal witli is, as a rule, sickness, and 
 sometimes it is extremely distressing. It is due, in the first 
 instance, to the anaesthetic. During my earlier experience I 
 was under the belief that the use of ether was more seldom fol- 
 lowed by sickness than was the use of any other anaesthetic, 
 but I must now say I do not think ether possesses any great 
 advantage in this respect ; but as I do not find patients suffer so 
 much from ether sickness after other operations as they do after 
 ovariotomy, I am inclined to believe the constriction of the pedi- 
 cle has something to do with the vomiting as well as the ether. 
 Whatever be the cause, it is certain that in a good many of my 
 operations there is a deal of trouble with sickness, sometimes 
 lasting as long as twenty -four or twenty-five hours. I have tried 
 a great many means of arresting this ugly symptom, and by far 
 the most effectual I find to be the administration of tepid water, 
 slightly flavored with brandy. I never now use ice for this 
 purpose, as I have not found it very efficacious. It gives rise 
 to intolerable thirst, and this is altogether avoided by the use of 
 tepid water. Should there be any pain after the operation, I 
 direct the use of a suppository containing one-fourth of a grain 
 of morphia, but with this agent I am extremely cautious, for 
 my patients never get a single dose of morphia or opium more 
 than is absolutely necessary to relieve pain. Like other opera- 
 tors, I have long since discarded the routine use of opium, which 
 was the fashion at one time, a practice brought into existence 
 by the idea that it prevented the occurrence of peritonitis. With 
 my patients as little as possible is done in the after treatment, 
 each symptom being dealt with only as it arises, and it is quite 
 exceptional for me to have to subject them to any active inter- 
 ference. 
 
 The ice cap seems to be in very constant use at the Samari- 
 tan Hospital, but I have never yet employed it. We hear of 
 some thousands of pounds of ice being used every year for it, 
 and I have been told that a large cistern has been erected at the 
 top of the hospital, with pipes distributed all over the building, 
 for the purpose of supplying iced water to the patients' heads. 
 Dr. Bantock's explanation of this is to the effect that it is necessi- 
 tated by the amount of carbolic acid used in some of the opera- 
 tions. In my own practice I have never seen cases of exaltation 
 of temperature, except in cases where the Listerian details 
 were fully carried out, or where the clamp was used. It never 
 seemed to me that the use of the ice cap was at all a rational 
 proceeding, but whether I am or am not correct on this point is
 
 308 DISEASES OF THE OVARIES. 
 
 not a matter of much importance. I have never used it and my 
 mortahty is much smaller than the mortality where the ice cap 
 is used. 
 
 When from some reason or another the patients begin to do 
 badly, the first indication is an altered expression of the face. 
 I am unable to describe this change of countenance, but I 
 learned to recognize it only too well in the old days when, from 
 the use of the clamp, my mortality ran high. Associated with 
 this changed expression is a rapidly increasing abdominal dis- 
 tention, speedily followed by vomiting. At first the vomited 
 matter is simply the fluid the patient has swallowed, but soon it 
 becomes tinged with bile. Later on, should the patient grow 
 worse, the vomited matter becomes entirely bilious, and toward 
 the end it gets quite black and characterized by these features 
 to which the name of " coffee ground" vomiting has been aptly 
 given. In those instances where death followed the use of the 
 clamp, the plienomena always began on the second or third day, 
 the patient dying on the fourth or fifth ; and when once these 
 fatal symptoms had become fairly established, nothing I ever 
 did could arrest them. To recapitulate here the therapeutic 
 experiments based upon all kinds of hints, derived from reading 
 and from the advice of friends, would be perfectly needless, for 
 in not a single instance did I ever see beneficial effects from any 
 of them. 
 
 On opening the abdomen after death the uniform appearances 
 were found to be those of diffuse suppurative peritonitis. It 
 was impossible to trace in every instance the exact cause of 
 death, yet sufficient evidence was obtained to make me attribute 
 the fatal result in such cases to the presence of a minute aper- 
 ture in the wound, at the point where the pedicle was embraced, 
 through which the discharges from the ulcerated surface under 
 the clamp penetrated into the abdominal cavity. With the 
 discontinuance of the clamp such cases as these have entirely 
 disappeared, and now not only is it quite exceptional to have a 
 fatal case, but it is quite unusual to have any anxiety concerning 
 my patients' recovery. Sometimes bilious vomiting occurs, why 
 I hardly know. I cannot think this a very dangerous symptom, 
 for I can recall but one instance of its being so persistent as to 
 give rise to anxiety. As soon as the vomited matter shows 
 signs of bile, I give some mild laxative, generally a seidlitz 
 powder or a teaspoonf ul of Epsom salts, and a small dose of calo- 
 mel, and the symptom is speedily brought to an end. 
 
 With reference to movement of the bowels after an abdom- 
 inal operation. I have entirely lost all the fears derived from 
 tradition, and I never take any steps to prevent their ordinary
 
 OVARIOTOMY. 309 
 
 motion, indeed the administration of laxatives within a few 
 hours after the operation is becoming quite a common practice 
 with me, this innovation, in my opinion, being possibly conducive 
 in some measure to my increased success. 
 
 Concerning fatal cases I am altogether of Dr. Keith's opin- 
 ion, that the very first search to be made for an explanation 
 should be in the details of the operation, and every fatal case 
 occurring to me is subjected to most rigorous inquiry. Some- 
 times I have found reason to suspect some omission or commis- 
 sion on my own part ; in others I thought the surroundings 
 were at fault ; while in other instances I have been totally un- 
 able to account for the catastrophe. Two of my fatal cases, 
 where the ligature had been used, were due to intestinal obstruc- 
 tion, and this arose from a kind of paralysis of the intestines 
 which was perfectly inexplicable. Dr. Battey tells me he has 
 seen the same thing. In both instances the patients had made 
 satisfactory progress until the sixth day after the operation, 
 without the slightest interruption, when suddenly the abdomen 
 became greatly distended, incessant vomiting occurred, and the 
 patients rapidly sank. After death nothing could be found ex- 
 cept enormous distention of the abdomen by fluid faeces and 
 gases. In both cases temporary relief was produced by tapping 
 the intestines. The only explanation I can offer of the fatality 
 in these cases is that some mysterious influence, similar, perhaps, 
 to that which causes tetanus, brought about this unexpected and 
 inexplicable end. 
 
 One of my recent deaths arose from a cause which will serve 
 to show how much care should be exercised in watching the ac- 
 tions of those who play less prominent parts in our operations, as 
 well as in conducting our own proceedings. A death had oc- 
 curred in the hospital from a distinctly septic cause, in a case 
 under the charge of one of my colleagues, and after death the 
 body was allowed to remain in the ward for an unnecessarily 
 protracted time. My patient was placed in the same ward 
 within a very few hours afterward, and though her operation 
 was performed with complete Listerian precautions, within a 
 very few hours she had all the indications of acute septic poison- 
 ing and died in less than eighty hours. Unfortunately, it was 
 not until after the accident had occurred that I became aware 
 that the directions which up to that time had always been care- 
 fully carried out, had in this instance been omitted. The les- 
 sons to be derived from that unhappy circumstance are twofold: 
 that no precaution can be too great in guarding against such a 
 catastrophe, and that the Listerian details cannot be relied upon 
 to prevent septic poisoning.
 
 310 DISEASES OF THE OVARIES. 
 
 Dr. Bantock has drawn attention to a distinct danger in- 
 volved in the employment of carbolic acid after Lister's method, 
 v^hich I had not recognized until he pointed it out, but since 
 that time I have seen three marked cases of it, and, looking 
 back upon my own practice, I find record of what, I have very 
 little doubt, was a fatal case of carbolic acid poisoning. What 
 I allude to is the alteration of the urine, which is well known to 
 be a result of the use of carbolic acid. Some months ago I had 
 occasion to open the abdomen of a child, placed under my care 
 by Dr. Totherick, of Wolverhampton, on account of a pelvic 
 abscess communicating with the bladder. The operation was 
 performed with complete Listerian details. Within twelve 
 hours of the operation it was observed that the child's urine 
 possessed the characteristic color given by indican, and that the 
 small amount of albumen which had been recognized in the 
 urine previous to the operation had increased to such an extent 
 that the deposit after the urine was boiled occupied nearly half 
 the tube. Twelve hours after convulsions occurred, and the 
 child became comatose. My colleague, Dr. Heslop, whom I 
 asked to see the patient, regarded the symptoms as perfectly 
 characteristic of meningitis, and he gave a prognosis of an un- 
 favorable kind. I was, however, strongly impressed with the 
 belief that the child was suffering from carbolic acid poisoning. 
 This opinion was, I think, sustained by the events, for tho 
 indican disappeared, the albumen diminished, the convulsions 
 ceased, the child regained consciousness, and in about six days 
 after the operation the whole train of symptoms had passed 
 away. In another child upon whom I did abdominal section I 
 saw similar, though by no means such severe symptoms, and 
 in a full-grown woman of twenty-four years of age I again saw 
 them repeated. One of the first operations I performed on the 
 Listerian method died in thirty-six hours after the operation 
 with complete suppression of urine; and my belief now is that 
 she died of acute carbolic acid poisoning, though, as I did not 
 recognize such a possibility at the time, I am not prepared to 
 say absolutely that it was so, but I have never seen suppression 
 of the urine, or any alteration of it, such as I witnessed in these 
 cases, save where carbolic acid had been freely used. Years 
 ago, when we used carbolic acid of the strength of one in four as 
 the carbolic oil, it was a very common thing indeed to see seri- 
 ous urinary symptoms associated with its employment, and I 
 am perfectly certain that a great many fatal cases of carbolic 
 acid poisoning are caused by the too free and even indiscriminate 
 use of this poisonous agent. 
 
 I have no very fixed rules concerning the diet of my patients
 
 OVARIOTOMY. 811 
 
 recovering from an ovariotomy, save that as long as there is 
 any tendency to sickness they liave no solid food. But I do not 
 put them through a term of three or four days systematic star- 
 vation as I formerly did. Toward the end of the first or the 
 beginning of the second day they are allowed to have some 
 beef-tea or milk. The first solid food they get is either some 
 custard pudding, some dry toast, or a little boiled fish, and 
 these are cautiously followed by a little boiled chicken, or, in- 
 deed, whatever they may express a particular fancy for, if the 
 preference be a reasonable one. If the bowels show no indica- 
 tion to move of their own accord by the third or fourth day, an 
 enema is given and repeated at intervals until it has the desired 
 effect. 
 
 The dressing of the wound is limited to absorbent wool or a 
 little zinc ointment if stitch-hole abscesses should form, or 
 some of the old red lotion if the wound should gape anywhere. 
 The stitches are removed between the sixth and eighth days, 
 and the patients are generally up between the fourteenth and 
 twenty-first. 
 
 Before the patients are allowed to be up they are always pro- 
 vided with a well-fitting abdominal belt, and this they are 
 earnestly enjoined never to be without, while in the erect posi- 
 tion, for at least a year after the operation. If this injunction 
 be obeyed, there is never any tendency to protrusion of the in- 
 testines ; but with hospital patients it is almost impossible to get 
 these orders carried out, and the consequence is that it is not 
 unusual to find them return in about three or four months with 
 a hernial protrusion, while in private practice this is almost un- 
 known. 
 
 One of the many arguments used against the intra-peritoneal 
 method of dealing with the pedicle was that the stump might 
 contract adhesions to a loop of intestine and produce strangula- 
 tion, or that an abscess might form round the ligature and give 
 rise to much trouble. So far as I know the results of my prac- 
 tice, in not a single instance have these anticipations been 
 fulfilled. I direct my patients to see me or write to me every 
 two months after their operations, and I keep a correct record 
 of their visits and letters, and therefore I think I may say that I 
 watch the after-results of my operations with exceptional care. 
 
 In my earlier practice I laid great stress upon the practice of 
 keeping the pelvis quiet, as I thought, by preventing the patient 
 passing water for herself, and emptying her bladder every five 
 or six hours regularly by the catheter. One source of trouble 
 which arose from this practice was the frequent occurrence of 
 cystitis, which in several instances assumed great severity and
 
 312 DISEASES OF THE OYAEIES. 
 
 gave rise to a very great deal of anxiety. I found that in most 
 cases this arose from the carelessness of the nurses, for it was 
 almost impossible to get them to understand what a clean 
 catheter really meant, and I had to resort to the expedient of 
 having the instrument, when not in use, always kept in a basin 
 of water. If this simple precaution was properly attended to, 
 my patients always escaped inflammation of their bladders ; but 
 even with the most scrupulous injunctions, a case of cystitis 
 would occasionally occur. I therefore use the catheter now as 
 little as possible, and my patients are always encouraged to pass 
 water for themselves as soon as they can. Owing, however, to 
 some reflex influence, arising doubtless from irritation of the 
 nerves of the pedicle, they are sometimes quite unable to pass 
 water for several days after the operation, and then the catheter 
 must be employed with the precautions I have already indi- 
 cated ; and if it is to be used, let me urge the absolute necessity 
 of these being attended to. 
 
 Another danger in this matter is to be avoided — one which is 
 occasionally overlooked — over-distention of the bladder. I re- 
 member being told on two consecutive days, at each of my vis- 
 its, by one of my most intelligent nurses, that a patient was 
 passing her water all right. She was an extremely nervous 
 patient, and the complaint she made of pain at first did not at- 
 tract my attention ; but at last I examined the bladder, and 
 found it completely distended, although the nurse had informed 
 me that she had passed a quantity of urine only a few minutes 
 before my visit. The fact was that what she had passed was 
 the mere overflow, and probably the patient's bladder had been 
 distended for forty-eight hours. Thus, upon the slightest com- 
 plaint on the part of the patient in the region of the bladder, a 
 careful examination should be made. Fortunately in the case I 
 have alluded to no harm ensued, but every consultant knows 
 how frequently we are called in to see cases where the bladder 
 has been allowed to remain over-distended for many days after 
 a labor, and too frequently this is followed by terrible disasters. 
 
 For the treatment of cystitis arising from the use of a foul 
 catheter, or from over-distention, I know of nothing equal to the 
 injection into the bladder of a tepid solution (five per cent.) of 
 hyposulphite of soda, and the administration every eight hours 
 of a soluble pessary containing three or four grains of extract 
 of belladonna. 
 
 The after-course of a case of ovariotomy is subject to many 
 rude checks, which alter its history very much from the fortu- 
 nate career supposed in the preceding pages. There are many 
 dangers in the path of every patient submitted to this operation.
 
 OVARIOTOMY. 313 
 
 and there are many indications of their approach, but none so 
 trustworthy as those derived from a close observation of the pa- 
 tient's temperature-curve. It should be the invariable j^ractice 
 of the surgeon to have temperature and pulse observations of 
 his patient made night and morning for a few days before the 
 operation, and afterward these ought to be repeated every four 
 hours for at least ten days. Nothing has been to me more in- 
 structive than a comparison of a group of such charts ; and I 
 have repeatedly seen grounds for a prognosis in a case by the 
 comparison of its temperature-range with those of former cases. 
 It will almost invariably be found that, immediately after the 
 operation, the temperature falls considerably. I have seen it do 
 so as much as two degrees, indicating the risk the patient has 
 to run in the form of shock. To obviate this being carried to a 
 dangerous extent, it is always well to place hot water bottles to 
 the sides and feet, and, if depression be severely marked, to ad- 
 minister a diffusible stimulant. By far the best is an enema of 
 diluted champagne, with a little brandy. It is generally neces- 
 sary to administer a small dose of morphia — one-third or one- 
 fourth of a grain — immediately after the operation, by supposi- 
 tory, and by this I believe shock may be warded off in great 
 measure, and the after-sickness prevented. 
 
 From the twelfth to the twentieth hour after the operation, 
 the temperature slowly rises, unless the patient succumb to the 
 shock ; or, in the still rarer condition, where the operation has 
 had to be undertaken on an emergency due to cyst-inflamma- 
 tion or an attack of peritonitis, in which case the temperature 
 falls. In a case of the latter, where I operated with a tempera- 
 ture of nearly 40° Centigrade, it fell in twenty-four hours to 37°. 
 
 After the recovery from shock, the patient generally breaks 
 out into a gentle perspiration, and this should be slightly en- 
 couraged, and the temperature may vary from 3G.8° Centigrade 
 to 38.5° without giving rise to any alarm. If it rise, however, 
 above the latter point, especially if accompanied by an in- 
 creased pulse frequency, dry tongue, pain, and inflation of the 
 abdomen, green vomiting or hiccup, and anxious face, the ac- 
 cess of peritonitis, in some form or other, may be taken for 
 granted. The treatment of this must vary very much accord- 
 ing to the circumstances of each case. 
 
 Vomiting and distention used to be, as I have said, an inva- 
 riable indication of an ultimate fatal issue. In the old days of 
 the clamp, when we saw these symptoms come on accompanied, 
 as they always were, by the unmistakable expression of face, 
 we knew only too well that our efforts had been in vain. Now 
 it is extremely rare to see either of these symptoms of an extent
 
 314 DISEASES OF THE OVAKIES. 
 
 sufficient to give rise to much anxiety. We do see sickness, and 
 sometimes it is green and bilious, and we occasionally have 
 some little distention, but they very rarely cause us any trouble. 
 For the treatment of the sickness, I find the most effectual rem- 
 edy to be a small dose of sulphate of magnesia, thirty or forty 
 grains in tepid water, repeated every other hour or every hour 
 until the bowels have moved, or two and a half grains of calo- 
 mel given every three or four hours until a similar effect is 
 produced, v 
 
 The distention is nearly always started in the transverse 
 colon, and shows itself first at tlie scrobiculis cordis, which, 
 after an ovariotomy, is usually concave. I look at every visit 
 at this point, and teach all my nurses also to watch it carefully, 
 and as soon as any distention is visible, a tube is passed into the 
 rectum at intervals of two or three hours, and left in a short 
 time to enable the flatus to escape. If either of these symptoms 
 advance to any alarming extent, I use still more active meas- 
 ures to get the bowels moved, because I always find that as 
 soon as a motion has passed they rapidly disappear. 
 
 If, at the time of the operation, it has been thought necessary 
 to follow the plan of drainage, as introduced by Koeberle and 
 Keith, a little extra care must be taken with the case. I have 
 now had considerable personal experience of this method, and 
 I am quite satisfied from the cases in which I have used it, 
 and from Avhat I know of Dr. Keith's work, that there will 
 occur every now and then a severe case in which it will be 
 found absolutely necessary to employ it. The tubes we use are 
 made of ordinary glass, formed somewhat like a test-tube, with 
 an overhanging lip with which they may be secured by one of 
 the sutures against the possibility of falling inside. They vary 
 in size and length, having a diameter of from three-fourths of 
 an inch down to one-fourth of an inch, their length being from 
 three to six or seven inches. In some of my operations upon 
 the liver, I have had to use them a good deal longer ; but for an 
 ovariotomy this length will generally be found quite enough — in 
 fact, it will rarely be necessary to use them more than four 
 inches long. For at least half its length the tube is perforated 
 with small holes through which the fiuid drains into it from the 
 cavity of the pelvis. Just before closing the wound, the tube is 
 placed with its bulbous end down into the cavity of the pelvis, 
 care being taken, of course, that it is placed behind the uterus, 
 and that it does not interfere with a loop of intestine. Very 
 soon after the wound is closed, it will be found that the serum 
 drains from it. and the amount of fluid which, in the course of 
 a very short time, will drain in this is simply amazing, for Dr.
 
 OVARIOTOMY. 315 
 
 Keith has shown me three huge bottles containing an aggre- 
 gate amount of probably ten or twelve pints drained from one 
 patient. 
 
 Now, whether it is or is not necessary to drain this large 
 quantity away is not yet a settled question. I believe that a 
 tube placed in a healthy peritoneum could be made to drain 
 away an indefinite quantity, for there is no doubt that the peri- 
 toneum, being a huge lymph-sac, is constantly passing lymph 
 either through the intestines outward or from the outer wall in 
 toward the intestines. The direction of this lymph-stream is 
 not known, nor, indeed, do we know anything about its physiol- 
 ogy ; but the facts of pathology are alone suflficiemt to determine 
 its existence. My own view about drainage is that it will be 
 useful only where some addition to this lymph-stream is made 
 greater than the outlet can carry away. The fact that I have 
 been so successful in my own operations without drainage 
 makes me think it probable that I have unconsciously substi- 
 tuted purgation for drainage ; for, on looking over my records, 
 I find that in very many of the cases where Dr. Keith would 
 have drained I have purged. This would make it seem as if the 
 intestines were to a large extent the outlets of the drainage 
 stream ; but it will remain for some time an open question whicli 
 of the two channels, the drainage-tube or the intestinal canal, 
 will prove the better vehicle. 
 
 Dr. Marion Sims' proposal to drain every case by means of 
 a tube passed from the abdominal cavity into the vagina was 
 one which did not meet with any very favorable reception, and 
 I feel quite sure that even in Dr. Keith's hands, where drainage 
 of a reasonable kind is resorted to, the cases vs^ill become fewer 
 and fewer ; but still there can be no doubt the drainage will 
 largely assist in relieving the strain upon that absorbent powder 
 of the peritoneum. 
 
 Dr. Keith, after fastening in the tube, places over it a wide 
 sheet of very fine rubber-cloth, through which the end of the 
 tube passes, and by the aperture in which it is firmly grasped ; 
 some carbolized sponges are then wrapped up in this cloth, and 
 in this way a very ingenious absorbent dressing is formed, 
 w^hich prevents the fluid, as it drains from the tube, soiling the 
 bed-clothes. Every hour or two the nurses squeeze the sponges 
 dry, or replace them by fresh ones, and this is continued as long 
 as the fluid is tinged red. sometimes for nearly a week. I em- 
 ploy a much simpler method. I merely apply two or three ab- 
 sorbent pads over the tube and change them when necessary. 
 
 The convalescence of a patient from an ovariotomy may br; 
 interrupted by any of the very many causes and accidental
 
 316 DISEASES OF THE OVARIES. 
 
 complications common to all surgical operations, but these are 
 found to be very greatly diminished by the increased care we 
 now bestow upon the hygienic arrangements of our hospitals. 
 Thus, formerly it was not an unusual thing to see a patient die 
 eight or ten days after an operation from an attack of pneumo- 
 nia, just the same as sometimes occurs in large hospitals after 
 amputations ; but in the admirable building of the New Infir- 
 mary at Edinburgh, Dr. Keith has already performed quite a 
 large number of operations with splendid success ; and but a 
 few days ago he told me, I think, that there he had done some 
 twelve or thirteen consecutive cases successfully without any of 
 the Listerian or so-called antiseptic precautions. 
 
 Once or twice, after the removal of very large tumors from 
 elderly women, I have seen a short, rapid cough set in, rapidly 
 increasing in severity, and killing the patient in about thirty 
 hours. What had occurred there was, I believe, perfectly anal- 
 ogous to the suffocative catarrh of old age. The expiratory 
 muscles, perhaps chiefly the diaphragm, from long want of 
 use, had become atrophied, and, missing their point d'appui in 
 the tumor, were unable to carry on the process of expectoration 
 of mucus. 
 
 Occasionally we have the occurrence of tetanus after ovario- 
 tomy, just as we have it after every other surgical operation. 
 Only once has it occurred in my practice, and the patient recov- 
 ered, probably because I did nothing at all to her, but left the 
 disease entirely alone. It is not a subject upon which therapeu- 
 tical experiments have produced any satisfactory results, and, 
 therefore, I think the less its victims are interfered with, the 
 more likely they are to get well. 
 
 Another nervous lesion I have seen occur twice after ovario- 
 tomy, and in both cases it has proved fatal, and several other 
 operators have told me that the}^ have had a similar unfortu- 
 nate experience. I refer to a paralysis, or what appears as 
 such, of the muscular coats of the intestine. The abdomen dis- 
 tends rapidly with gas, and when examined after death, noth- 
 ing is found but the distention. In both of my cases there was 
 nothing like peritonitis. I tried many things to relieve these 
 cases, including galvanism and puncture of the intestines, but 
 without benefit. 
 
 Great stress used formerly to be laid in all abdominal opera- 
 tions upon the necessity of keeping the bowels from moving, 
 and it was formerly ray practice to take pretty active measures 
 to prevent them acting for ten or twelve days. This practice I 
 have now entirely given up ; and should there not arise any 
 need for purging my patient, I let matters alone, desiring the
 
 OVAEIOTOMY. 317 
 
 nurses to give her an enema of warm water as soon as she ex- 
 presses any desire to have a motion, and to repeat this every 
 three or four hours until it is effectual. 
 
 I have so far only made casual allusions to cases of explora- 
 tory incisions and incomplete operations. It is very difficult, in- 
 deed, to lay down definite instructions upon this matter which 
 would be of much assistance to the beginner. Of course, in a 
 mere exploratory incision, made, let us say, for the purpose of 
 ascertaining whether the tumor is malignant or not, no special 
 difficulty will be experienced. In my own cases they really are 
 but open tappings ; that is to say, now-a-days, when we know 
 there is a quantity of ascitic fluid marking the outline of the 
 tumor, instead of tapping with a trocar, I simply make an in- 
 cision with a knife, large enough to admit my finger. I empty 
 the cavity, and, with my finger and my eye, I can generally 
 satisfy myself upon the points where I require information. 
 This sort of operation is nothing more than a tapping, and has 
 no more risk, so that I hardly class it amongst the list of explor- 
 atory incisions. What I mean by the latter term is when I 
 open the abdomen by an incision big enough, perhaps, to admit 
 my hand in order to determine whether the particular tumor 
 can or cannot be removed. Here there are one or two dangers 
 with which the inexperienced operator must be acquainted, and 
 which are not always to be avoided even by the most experi- 
 enced. Thus, in a soft uterine tumor, which may very closely 
 resemble an ovarian cystoma, it may very often happen that 
 the bladder is pulled with it right up out of the pelvis, and the 
 surgeon's knife may go through the bladder before he recog- 
 nizes it. This has three times happened to me, but I have 
 always carefully stitched the viscus up, and no harm has re- 
 sulted from the accident. Whenever, in an exploratory inci- 
 sion, the bladder is found pulled up and spread over the front of 
 the tumor for a considerable distance, the proceeding may at 
 once be brought to a conclusion, for it may be regarded as per- 
 fectly certain that the tumor cannot be removed. Another dan- 
 ger is in opening the capsule of a very vascular tumor, for it is 
 often a matter of the greatest difficulty to arrest hemorrhage 
 from such an incision ; and when the tumor looks very vascular, 
 and is probably uterine, let me strongly urge the operator, whose 
 experience is not very large, to be very cautious how he touches 
 it. unless he is prepared to proceed with and complete its re- 
 moval. It is at this point that the great question arises ; how 
 to direct an inquirer upon this difficult path I do not know, un- 
 less it- be to advise him that, before he engages much in abdom- 
 inal surgery, he had better see a good deal of it in the practice
 
 318 DISEASES OF THE OVARIES. 
 
 of some one else ; for the success of an operator is to be marked 
 not only by the number of successful operations he has per- 
 formed, but also by the diminution of those he has left incom- 
 plete. When and how to complete the removal of a tumor in 
 which there are grave difficulties can be learned only by expe- 
 rience, and, as I have elsewhere said, in my own earlier prac- 
 tice I too often left an operation unfinished which riper expe- 
 rience would have enabled me to complete. Let me here repeat 
 once again my advice that the surgeon should most carefully 
 consider what he is about to do before he turns an exploratory 
 incision into an incomplete operation ; but, after having once 
 determined the tumor to be a fit one for removal, let him pro- 
 ceed as speedily and as surely as he may, attending carefully to 
 the precautions I have already laid down, and, once having put 
 his hand to the task, let me say it will be wiser for him not to 
 turn back, but proceed to finish the work he has undertaken, 
 
 A most remarkable case was narrated in a paper communi- 
 cated to the Medico-Chirurgical Society of Edinburgh, in May, 
 1874, by Dr. Mathews Duncan. In this paper Dr. A. C. Camp- 
 bell, of Dundee, described a case of cystic tumor of the kidney, 
 simulating ovarian disease. The patient, aged forty-nine, a 
 mill-worker, had a tumor for about eighteen months in the left 
 flank, as large as a man's head, with fluctuation, and with 
 symptoms of ovarian disease. On exposure of the tumor and 
 insertion of the trocar, nothing came, as the contents were 
 like porridge. The tumor was therefore laid open, and two 
 pints of the stuff cleared out. Both ovaries were perfectly 
 healthy. It was found that the tumor was an altered kidney ; 
 it was, therefore, removed. The patient made a tedious, but 
 complete recovery. About forty ounces of urine were passed 
 daily. 
 
 As a fitting conclusion to this chapter I place a list of one 
 hundred and one consecutive operations for the removal of ova- 
 rian and parovarian tumors, performed without any of the Lis- 
 terian details, and forming, as may be seen from the dates, my 
 most recent experience. The table shows what seems to me the 
 best method of recording cases. The letters " H " and " P " mean 
 that the cases in the respective columns were in hospital or in 
 private practice. ''R" means recovery, and ''D" means that 
 the patient died. Of the hundred and one cases there were only 
 three deaths.
 
 OVAKIOTOMY. 
 
 319 
 
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 CHAPTER VI. 
 
 BECENT EXTENSIONS OF ABDOMINAL AND PELVIC SURGERY. 
 
 In a former chapter, when speaking of the pathology of the 
 ovary, I had occasion to point out that our recent advances in 
 pelvic and abdominal surgery have enabled us to obtain a great 
 deal of information concerning the diseases of the ovaries which 
 formerly were beyond our reach. It has been very well said 
 indeed that many of our recent operations, to which I pro- 
 pose here to devote some space, are quite as good as post-mor- 
 tem examinations for the purposes of pathology. I would say 
 that they are a good deal better, because we have by us, as part 
 of the justification for the operation, a complete clinical history 
 with which to compare the diseased appearances, and this we 
 never have at post-mortems, as far as the ovaries and tubes are 
 concerned. 
 
 In the chapter I have just alluded to, I give details of some of 
 the cases in which I have performed operations which, until 
 three or four years ago, I regarded as quite unjustifiable, but 
 which I now regard as the legitimate outcome of our increased 
 success in the removal of ovarian tumors. If Mr. Baker Brown 
 had continued to practise ovariotomy for some years after 1867, 
 he would speedily have brought his mortality down from ten 
 per cent. , at which he left it, to four or five per cent. , at which 
 Dr. Keith's mortality and my own now stand, and we should 
 have been fifteen years in advance of our present position. 
 From 1867, as I have already said, Mr. Spencer Wells exercised 
 an impregnable influence on the conduct of ovariotomy, owing 
 to the accident of circumstances, and with his mortality of twen- 
 ty-five per cent, any real advance of abdominal surgery was 
 wholly impossible. No one could venture to submit a woman to 
 such a fearful risk unless her life was clearly menaced, and 
 therefore ovariotomy was always delayed as long ^s possible ; 
 palliative tappings and other blunders were perpetrated ; but 
 worse than all, the diseases in the pelvis and abdomen which
 
 RECENT EXTENSIONS OF ABDOMINAL AND PELVIC SURGERY. 323 
 
 were amenable to surgical treatment, but which did not im- 
 mediately and evidently destroy life, were left alone, and the 
 patients went unrelieved. Dr. Thomas Keith ended this dark 
 period by showing us how to operate on the abdomen without 
 fear and with little risk, and these recent advances in pelvic and 
 .abdominal surgery should, in great measure, be placed to his 
 €redit, though I do not know that he has engaged in them in his 
 own personal practice to any large extent. 
 
 For my own part, so fearless am I now of abdominal surgery, 
 so splendid have been my results in fields of practice which, until 
 three years ago, seemed hopelessly enclosed, that I venture to 
 lay down a surgical law, that in every case of disease in the ab- 
 domen or pelvis, in which the health is destroyed or life threat- 
 ened, and in luhich the condition is not evidently due to malig- 
 nant disease, an exploration of the cavity should he made. I 
 have already published a great deal of work in support of this 
 proposition, and some of this I consider of sufficient importance 
 to reproduce at the close of this chapter. 
 
 In October, 1871, Mr. Hallwright, of Summer Hill, Birming- 
 ham, asked me to see with him a woman, aged forty-two, who 
 had suffered for years from agonizing pain in the pelvis, chiefly 
 ■on the left side, distinctly referable to the seat of the ovary, ac- 
 companied by a variety of reflex symptoms, of which the most 
 marked was complete and persistent aphonia. She had for many 
 years been under treatment at the hand of Mr. Hallwright and 
 others, without the slightest relief. We found the left ovary 
 large and very tender, displaced down behind the uterus, and 
 the slightest pressure upon it gave rise to the characteristic 
 sickening pain. From this pain she suffered on defecation. 
 After having seen the patient many times, and after careful 
 thought, I ventured to suggest to my colleague that removal of 
 the ovary would probably cure her. I recognized the gravity of 
 the proposal, for I had no fear that her sufferings would kill her, 
 and she had only some six or eight years to live before the cli- 
 macteric period would bring relief ; but both Mr. Hallwright 
 and I thought it was better that the suffering should be saved 
 her for that period, even at some risk of life, than that it should 
 be continued, making life a burden to her and to all her sur- 
 roundings. The patient and her friends arrived at quite the 
 same conclusions when the matter was explained to them, and 
 the operation was decided upon. With the assistance of Mr. 
 Hallwright and Mr. Bennett May, I performed it on February 
 11, 1872, and found the ovary non-adherent, as large as a 
 pigeon's egg and full of thick, grumous matter, which, at the 
 time, I took to be the fat of a dermoid cyst. More careful exam-
 
 324 DISEASES OF THE OVARIES. 
 
 ination has since made me believe that it was a chronic abscess, 
 for there is a complete absence of any skin structure in the walls, 
 and there were no appearances of any of the hair, teeth, etc., 
 which characterize dermoid tumors. So far as I know, this is 
 the first record in the history of surgery of the removal of a 
 small ovary on account of pain. The patient made a speedy and 
 complete recovery, and has ever since remained completely free 
 from pain in the pelvis. Her voice returned, and is now of nor- 
 mal power. She suffers now from some obscure disease which 
 has stiffened her knee-joints and makes her a cripple, but all the 
 symptoms which were in existence before the ovariotomy were 
 completely and permanently cured by it. 
 
 The success in this case suggested to me the possibility of re- 
 lieving other conditions of a kind involving risk to life by removal 
 of the ovaries, more particularly menstrual hemorrhage due to 
 uterine myoma. Every one knows what an intractable symp- 
 tom this is, how rarely it yields to the most energetic treatment 
 of a therapeutical kind, and how many surgical expedients have 
 been devised for the purpose of dealing with it — enucleation of 
 the tumor, hysterectomy, etc. — all of which have had to be aban- 
 doned on account of a mortality so high that the operations be- 
 came wholly unjustifiable. Dr. Mathews Duncan and Professor 
 Gusserow, estimate that enucleation has a mortality of fifty per 
 cent., and hysterectomy one of seventy per cent. In my own 
 experience the mortality of the former has been much higher, 
 so that I have given the practice up, and have no hesitation in 
 denouncing it as unwarrantable on account of its risk. Con- 
 cerning enucleation, there is the additional objection that the 
 tumors grow again, at least in the three cases in which I have 
 enucleated successfully, this has been the uniform result. Di- 
 viding the cervix has also proved a wholly useless operation, 
 for even where it has given relief it has done so only for a 
 very short time. Hypodermic injections of ergotin and in- 
 jections of astringents and styptics into the uterus have also 
 proved useless and very dangerous, especially the latter ; for I 
 have had three deaths from it in some ten or eleven cases. Yet 
 in these cases something must be done, for the hemorrhage 
 proves fatal in a large number of them, and even when it does 
 not do so, it utterly destroys the health and usefulness of the 
 lives of the sufferers. 
 
 In a recent discussion on this subject at the International 
 Medical Congress in London, Dr. Mathews Duncan expressed 
 the astonishing opinion that such cases did very well if left alone, 
 and did not demand any risky interference, yet he records with-
 
 RECENT EXTENSIONS OF ABDOMINAL AND PELVIC SURGERY. 325 
 
 out condemnation the high mortality I have quoted in the cases 
 of enucleation and hysterotomy. 
 
 I remember very well the first case of death which I witnessed 
 from menstrual hemorrhage due to a myoma occurred in Dr. 
 Mathews Duncan's own practice, while I was a pupil at the 
 Edinburgh Infirmary in 1862. The case was impressed on my 
 memory because I made a post-mortem examination of the pa- 
 tient and carried the tumor to Dr. Duncan. Since that time I 
 have seen many deaths from this cause. But even if only a 
 few of the cases died, their sufferings are severe and pro- 
 tracted, and they are permanent invalids. As an illustration of 
 this, I cannot do better than quote a letter from Dr. Law Webb 
 concerning a patient upon whom I have recently performed a 
 successful operation of the kind I am now discussing, on ac- 
 count of a tumor which grew after its predecessor had been re- 
 moved by enucleation : "When I first came to this neighbor- 
 hood (Ironbridge, Salop), Miss F. was one of the ' confirmed 
 invalids ' of the place, and had been in failing health for some 
 years before that date (1870). I must have attended her at 
 short intervals for more than nine years. She had profuse 
 hemorrhage at every monthly period, and sometimes every fort- 
 night for months together. Treatment did so little good that 
 she usually only sent for me when the loss was unusually great, 
 or her anaemic condition alarmed her friends. Her life cer- 
 tainly has been a misery to her for the last ten years, as she 
 has been ill and laid by more than half her time." This graphic 
 description might be applied to scores of cases, and if our art 
 is to be withheld from them, when we have an absolute cure 
 in our hands for them, of what use can we claim to be ? The 
 answer might very fairly be made to Dr. Duncan that there 
 must be a pecuniary inducement in keeping our patients in 
 chronic ill health, when they might be promptly cured. That 
 there is a risk of life attached to such an operation is no argu- 
 ment against it ; at least it would be an argument equally strong 
 against every kind of medical and surgical treatment, and would 
 be equally logical against railway travelling. The only effect of 
 the statement should be to reduce that mortality as close to a 
 vanishing point as may be, and I am satisfied that can be largely 
 accomplished. 
 
 I have said that the success with Mr. Hallwright's patient 
 induced me to extend the principle, and on the first of August, 
 1873, I removed both ovaries for the purpose of arresting men- 
 strual hemorrhage, of a perfectly intractable character, in a wo- 
 man, aged forty, who had been for some months under my care.
 
 326 DISEASES OF THE OVARIES. 
 
 The result was a complete success, and I heard of the patient 
 being alive and well in 1874. The same idea, concerning the re- 
 moval of small ovaries, had struck the minds of two other sur- 
 geons about the same time as it occurred to me, for up to July 
 27, 1872, five days before my second case. Professor Hegar, of 
 Freiburg, removed both ovaries for neuralgia, with a fatal result ; 
 and on the 17th of August of the same year. Dr. Battey, of Rome, 
 Ga. , successfully operated upon a patient suffering from serious 
 and complicated symptoms. Dr. Battey was the first to publish 
 his cases and a defence of his proceedings {Atlanta Medical 
 Journal, September, 1872), whilst I contented myself with dis- 
 cussing the principle only in my Hastings' Essay on " Diseases 
 of the Ovary " (1873). 
 
 For the removal of small ovaries, Dr. Battey first introduced 
 the phrase " normal ovariotomy," a great mistake, for it was 
 at once assumed that we proposed to remove healthy ovaries, 
 on slight or insufficient provocation, whereas, with very few 
 exceptions, the organs are all diseased. This unfortunate 
 phrase has been a great stumbling-block, and has excited an 
 amount of opposition, both professional and public, from which 
 abdominal surgery, and those who practise it, have suffered 
 not a little. The terms "spaying" and '' castration of women " 
 (Hegar) were equally objectionable for the same reason, and 
 further from the fact that, as far as my practice is concerned,, 
 they do not express the facts of the operation. Dr. Marion 
 Sims has attempted to give it the name of " Battey' s opera- 
 tion," but this will not do for very many reasons. Dr. Sims 
 compares it with, and seeks the authority of precedent from 
 "Amussat's operation "or " Syme's amputation." But there 
 is no parallel at all in these cases, for in both the proceedings 
 are definite, and practically do not vary ; whilst in the operation 
 I am now discussing, the details vary indefinitely, and so do al- 
 most equally the principles upon which the operations are per- 
 formed. For an operation performed merely to " bring about 
 the menopause," to quote Dr. Battey 's definition of his own prin- 
 ciple, there must be but a limited field, and my own experience 
 of it would be vague and indefinite, and my conclusions would 
 be doubtful. Again, neither Prof. Hegar nor Dr. Battey seems 
 to have recognized the importance of the tubes in these cases, 
 nor to have contemplated their removal for occlusion and dis- 
 tention. This is an extension of pelvic surgery entirely my 
 own. 
 
 Similarly, I have a strong objection to the pedantic inven- 
 tion ''oophorectomy." This properly describes the removal of 
 an ovarian cystoma as completely as it does a "Battey's opera-
 
 RECENT EXTENSIONS OF ABDOMINAL AND PELVIC SURGERY. 327 
 
 tion/' In my own practice the conclusion is indicated that re- 
 moval of the Fallopian tubes is more important than removal 
 of the ovaries, and in by far the larger number of my cases that 
 alone might have sufficed ; indeed, in many it has done so. 
 Therefore, if Greek inventions must be introduced, I should ask 
 for " salpingotomy " or " salpingo-oophorectomy," or ''prosthe- 
 kotomy," if the pedantry were not ridiculous. But I do not 
 propose to attempt any reforms or additions to our clumsy no- 
 menclature. When I remove an ovary I call the operation 
 '" ovariotomy,"' and by describing the disease for which the op- 
 eration was done, I leave each critic to class my cases as seems 
 best to him. When I remove diseased tubes I generally, but by 
 no means always, remove the ovaries with them, and in these 
 cases I speak of the operation as ' ' removal of the uterine ap- 
 pendages.'' 
 
 For the purpose of classification I arrange the operations 
 which I have performed upon the uterine appendages on account 
 of (a) pain, (b) intractable hemorrhage, and (c) reflex symptoms. 
 Up to the date of writing they have all been published in detail, 
 save some of the most recent, and it would be quite impossible, 
 within reasonable limits, to republish these details here. A list 
 of cases was submitted to the Obstetrical Section of the Inter- 
 national Congress, with columns containing the residence and 
 names of the medical attendants of the patient, so that each 
 case might be identified if necessary. The first criticism which 
 my work met with was that the statements of it were not true — 
 a criticism which no one had the hardihood to make in public, 
 but which was diligently circulated by some of whom I ex- 
 pected better things. 
 
 The next criticism was that I was " spaying women — remov- 
 ing healthy ovaries from healthy women"' — a statement which 
 has been reiterated by many medical journals, including so well- 
 informed an organ as the Lancet. Even text-books in gynaecology, 
 such as that of Hart and Barbour, speak of my "excising the 
 ovaries for hydrosalpinx and pyosalpinx," so that I have become 
 almost tired of the discussion. 
 
 I hope it may be for the last time that I give an emphatic de- 
 nial to all this sort of thoughtless misrepresentation. 
 
 The principles of this extension of abdominal surgery are few 
 and clear, and for their establishment I think I can give satis- 
 factory arguments. 
 
 The first class of cases in which we may interfere is the 
 most doubtful, and certainly the most restricted, and it is that 
 to which the term " Battey"s operation,"' if it must be used at 
 all, should be confined. It is those in which there is no physical
 
 328 DISEASES OF THE OVARIES. 
 
 evidence of pelvic disease, yet where there are serious symptoms 
 so intimately associated with menstruation as to lead us to be- 
 lieve that an arrest of that function might cure or relieve the 
 patient by the establishment of a " premature menopause." 
 
 It must be perfectly evident that this is such an extremely 
 vague field that it may be either very limited or very much ex- 
 tended. I have been so very doubtful about it that I have lim- 
 ited it entirely to one well-pronounced disease — epilepsy. 
 
 There is no difficulty in defining true epilepsy, and we find 
 that almost every epileptic woman is worse during the men- 
 strual week. In some patients the fits are confined absolutely 
 to the menstrual period, and then we speak of "menstrual 
 epilepsy." I have had very many such cases sent to me for the 
 purpose of having the operation performed, but I have limited 
 the proceeding to five cases, all of them being patients where 
 the disease had resisted all other treatment, where the intellect 
 of the patients had become affected, and their usefulness to 
 society completely impaired, their lives even being threatened. 
 One such case is narrated in full in another chapter (p. 107 et 
 seq. ), and others have been published. All five patients recovered 
 and are still alive. 
 
 The second case I operated upon was a girl, aged eighteen, who 
 had been imbecile from birth, and who had developed the most 
 violent menstrual epilepsy from the time of the molimen. For 
 some months before the operation she had been so bad during 
 the period as to require the constant care of two attendants, and 
 Mr. Green, the superintendent of the asylum of which she was 
 an inmate, was quite satisfied that the disease would shortly 
 prove fatal. I operated on May 9, 1880, with the result of com- 
 pletely arresting menstruation and abolishing the epilepsy. 
 She is still an inmate of the Birmingham Borough Asylum, and 
 is quite manageable. She gives slight indications of an in- 
 creased noisiness and loquacity at the time at which her periods 
 should occur, and occasionally at these times she has an attack 
 oi petit mal ; but her violent epilepsy has quite disappeared, and 
 remains in abeyance now, more than two years and a half after 
 the operation. 
 
 In the third case the girl remained free from the fits for 
 about six months, but they are now returning occasionally, so 
 that I fear the case will prove a failure, though the operation 
 has completely arrested menstruation. 
 
 The fourth and fifth cases are of too recent date to express 
 any opinion about. In both menstruation is completely arrested, 
 but the fits have not disappeared. Of the fifth. Dr. Knipe, of 
 Melbourne, writes to me that she is very much improved so far.
 
 RECENT EXTENSIONS OF ABDOMINAL AND PELVIC SURGERY. 329 
 
 It will be seen from this, and from the fact that I have sus- 
 pended for the present further trial of the operation in such 
 cases, that I am not greatly in favor of " Battey's operation." 
 Its results, as far as the recovery of the patients are concerned, 
 are satisfactory enough. The removal of the appendages in 
 such cases is the easiest operation possible, and ought never to 
 be fatal. Its secondary results are uncertain, and I am not dis- 
 posed, in the present aspect of professional opinion, to hamper 
 my work in other directions by its discussion further at the 
 present time. To operate in this class of neurasthenic cases, 
 where the symptoms are all subjective and the physical signs 
 negative, is a question for further discussion, and for its settle- 
 ment I have absolutely no material. 
 
 For the arrest of intractable hemorrhage the removal of 
 the uterine appendages offers a most satisfactory field, as I have 
 already shown (pp. 115 and 153). The primary risks of the op- 
 eration are small, as is shown in the table on next page, which 
 embodies the whole of my recent experience of such cases, 
 dating from the time when the advance of abdominal surgery 
 made such operations possible. For small tumors, where it is 
 an alternative to enucleation, it is far safer, and it offers the 
 security against a return of the disease which enucleation does 
 not. In the case of large tumors it is an alternative, in the 
 great majority of instances to hysterectomy, than which it is 
 also much less fatal. In the great majority of cases it arrests 
 the hemorrhage and the growth of the tumor at once, and in 
 many the tumors shrivel and absolutely disappear. In such as 
 do not disappear it might form a preliminary step to hysterec- 
 tomy, though I never made such a use of it. 
 
 Hemorrhage was, of course, the leading feature in nearly all of 
 these cases, but in many of them the pain and discomfort alone 
 would have justified the operation. In the two cases which were 
 fatal the anaemia was extreme, and the operation had not a fair 
 chance. In case No. 33 the patient died of cancer about five months 
 after the operation. At the time of the operation there was 
 no appearance of the tumor being malignant, but by the kind- 
 ness of Dr. Totherick I saw it after death, and there was no 
 doubt of it being cancer. This is the kind of after-history in 
 ovarian tumors of which I have already spoken at length, and 
 doubtless it will be met with in myoma when we know more 
 about that disease. One other case (23) has died since the opera- 
 tion, but I do not know anything as to the cause of death. So 
 far as I have been able to learn, and that includes all the rest 
 but two, the other cases are alive and well, and the secondary 
 results of the operation are quite satisfactory.
 
 330 
 
 DISEASES OF THE OVARIES, 
 
 FORTY-FIVE CASES OF REMOVAL OF THE UTERINE APPENDAGES FOR 
 
 MYOMA. 
 
 Ko. 
 
 Residence. 
 
 Medical Attendant. 
 
 Age. 
 
 ofk\ «-*- 
 
 Hosp. 
 
 P 
 
 . ! R. 
 
 1 R- 
 
 . 1 R. 
 
 R. 
 R. 
 . R. 
 R. 
 R. 
 R. 
 R. 
 R. 
 R. 
 
 R. 
 
 R. 
 R. 
 R. 
 R. 
 R. 
 R. 
 R. 
 R. 
 R. 
 R. 
 R. 
 
 R. 
 R. 
 R. 
 R. 
 R. 
 R. 
 R. 
 R. 
 R. 
 R. 
 R. 
 R. 
 R. 
 R. 
 R. 
 R. 
 R. 
 R. 
 R. 
 R. 
 
 D. 
 
 1 
 9, 
 
 Leamington 
 
 Cannock 
 
 Dr. Tomkins 
 
 Dr. Tylecote 
 
 Mr. John Clay 
 
 Mr. Calvert 
 
 47 
 52 
 
 34 
 52 
 
 42 
 39 
 46 
 49 
 47 
 50 
 35 
 42 
 44 
 
 32 
 41 
 43 
 35 
 43 
 47 
 38 
 43 
 40 
 51 
 37 
 40 
 
 36 
 40 
 
 37 
 46 
 45 
 49 
 45 
 40 
 
 M 
 
 21 
 46 
 45 
 44 
 35 
 35 
 44 
 45 
 32 
 35 
 
 W. 
 W. 
 
 M. 
 
 S. 
 S. 
 M. 
 S. 
 M. 
 M. 
 S. 
 M. 
 W. 
 S. 
 
 M. 
 
 M. 
 M. 
 
 S. 
 M. 
 M. 
 
 S. 
 S. 
 M. 
 S. 
 
 s. 
 
 M. 
 
 M. 
 M. 
 
 S. 
 M. 
 M. 
 S. 
 M. 
 S. 
 M. 
 M. 
 S. 
 S. 
 M. 
 M. 
 M. 
 M. 
 M. 
 M. 
 M. 
 S. 
 
 1879. 
 
 Oct. 18.. 
 Nov. 30 . 
 
 1880. 
 
 Jan. 13 . 
 Mar. 10 . 
 April 7 . . 
 April 22 . 
 May 8... 
 Aug. 17. 
 Sept. 1 . 
 Sept. 2.. 
 Oct. 26.. 
 Oct. 16.. 
 Dec. 18 . 
 
 1881. 
 
 Jan. 13 . 
 Feb. 5 . . 
 Feb. 12 . 
 April 20. 
 June 15 . 
 June 17 . 
 Aug. 25 . 
 Aug. 27 . 
 Sept. 19. 
 Oct. 4... 
 Oct. 30.. 
 Dec. 27 . 
 
 1883. 
 Jan. 4 . . 
 Jan. 4 . . 
 Jan. 10 . 
 Jan. 29 . 
 Mar. 13. 
 Mar. 21. 
 Mar. 29. 
 Mar. 31. 
 April 8.. 
 April 11. 
 April 20. 
 April 27. 
 May 6 . . 
 June 9 . 
 June 12 . 
 June 16 . 
 June 27 . 
 July 13 . 
 Sept. 9 . . 
 Sept. 29 
 
 H. 
 
 H. 
 H. 
 H. 
 H. 
 
 H. 
 H. 
 
 H. 
 H. 
 H. 
 
 H. 
 H. 
 
 H. 
 
 H. 
 H. 
 
 H. 
 
 H. 
 H, 
 
 H. 
 
 H. 
 
 P 
 P 
 
 P 
 P 
 
 P 
 P 
 
 P 
 
 P 
 P 
 P 
 
 P 
 P 
 
 P 
 P 
 P 
 P. 
 P 
 
 P 
 P 
 P. 
 
 p! 
 
 p! 
 
 p. 
 
 p 
 p 
 
 
 3 
 
 Walsall 
 
 
 4 
 
 Southwell 
 
 
 5 
 
 Leicester 
 
 Chasetown 
 
 Solihull 
 
 Birmingham 
 
 Coventry 
 
 Stourbridge ....... 
 
 Bloxwich 
 
 Bradninch 
 
 Birmingham 
 
 Coventry 
 
 Dr. Clifton 
 
 
 6 
 
 Dr. Clarke 
 
 
 7 
 
 Dr. InsuU 
 
 
 8 
 9 
 
 10 
 11 
 12 
 13 
 
 14 
 
 Dr. Drummond 
 
 Dr. Fenton 
 
 Dr. Hammond Smith. 
 
 Dr. Somerville 
 
 Dr. Stephenson 
 
 Dr. J. W. Taylor .... 
 
 Dr. Plowman 
 
 Dr. D'Arcy Ellis 
 
 Dr. Kenny 
 
 D. 
 
 15 
 1R 
 
 Brierly Hill 
 
 Birmingham 
 
 Darlaston 
 
 
 17 
 
 Dr. Sutton 
 
 
 18 
 
 Droitwich 
 
 Dr. Cuthbertson 
 
 Mr. Hallwright 
 
 Dr. Law Webb 
 
 Dr. Kenny 
 
 
 19 
 20 
 21 
 
 Birmingham 
 
 Iron Bridge, Salop . 
 
 Birmingham 
 
 Wolverhampton . . . 
 
 Broseley 
 
 Ludlow 
 
 
 ??- 
 
 Dr. Pope 
 
 
 28 
 
 Dr. Bartlam 
 
 
 24 
 
 Dr. Brooks 
 
 Dr. Somerville 
 
 Mr. C. J. Bracey 
 
 Dr. Lycett 
 
 
 25 
 
 Bloxwich 
 
 n 
 
 26 
 27 
 
 Birmingham 
 
 Wolverhampton . . . 
 
 Gloucester 
 
 Conway 
 
 Llandudno 
 
 Birmingham 
 
 Birmingham 
 
 Wolverhampton . . . 
 
 Birmingham 
 
 London 
 
 Dudley 
 
 
 28 
 
 Dr. Eshelby 
 
 
 29 
 80 
 
 Dr. Pritchard 
 
 Dr. Nicol 
 
 
 81 
 
 Dr. Gaunt 
 
 
 82 
 
 Mr. Fairley 
 
 
 88 
 
 Dr. Lycett 
 
 
 34 
 35 
 36 
 
 Dr. J. W. Taylor 
 
 Dr. L. Atkins 
 
 L. T 
 
 
 37 
 
 Oxford 
 
 Mr. G. Jones 
 
 Dr. Fielding 
 
 Dr. Seaton 
 
 
 38 
 89 
 
 Alfreton 
 
 Southampton 
 
 Leicester 
 
 Droitwich 
 
 Chesterfield 
 
 Birmingham 
 
 Birmingham 
 
 Ludlow 
 
 
 40 
 
 Dr. Clifton 
 
 
 41 
 
 42 
 
 Mr. Spofforth 
 
 Dr. Hale 
 
 
 43 
 
 Mr. Bracey 
 
 
 44 
 45 
 
 Dr. Thomas 
 
 Dr. Brookes 
 
 
 H means hospital case. P, private case. R, recovery. D, death.
 
 RECENT EXTENSIONS OF ABDOMINAL AND PELVIC SURGERY. 331 
 
 I have already said enough about hydrosalpinx and pyosal- 
 pinx to render it quite unnecessary to discuss them further than 
 to insert here a complete list of all the cases upon which I have 
 operated for these diseases. Both conditions are far more com- 
 mon than was believed previous to my experience, yet they 
 have been quite well known, and described for at least half a 
 century. 
 
 Of the forty-four cases only four have occurred in single 
 women, and the leading feature in the history of many of the 
 cases was an attack of gonorrhcea. In one case I had to operate 
 in the acute stage of the disease, which had arisen, on the ad- 
 mission of the husband, from this cause. In many other cases 
 the origin of the condition could clearly be traced to an attack of 
 inflammation after a miscarriage or after a labor. 
 
 A very frequent feature in the history of the cases was found 
 to be that they had one child, and after that were never free from 
 pain till relieved by the operation. 
 
 The leading symptom is persistent pain, intensified at the 
 periods, especially just before their onset, and always made 
 worse by intercourse. In the great majority of the cases mar- 
 ried life had to be completely suspended, and the function was. 
 always restored by the operation. 
 
 Metrostaxis, sometimes so severe as to amount to hemorrhage,- 
 is a very frequent symptom, though in some of the cases men- 
 struation is scanty. 
 
 Of course if the disease is bilateral the patients are sterile, 
 and this is usually the case, though in some only one tube 
 has been found to be affected, and then that only has been re- 
 moved. 
 
 The operations are generally very difficult, for it is quite ex- 
 ceptional not to find the tubes and ovaries densely adherent tO' 
 the viscera and to the pelvic wall, and in some of my operations 
 the difficulty in overcoming these adhesions has transcended 
 anything I have ever seen in the removal of cystic tumors of the 
 ovary. In some cases the hemorrhage during the operation has 
 been alarming, but it has always been controlled by sponge- 
 packing. In three of the cases the diseased organs have been 
 removed only at a second attempt; that is, in my early practice 
 I had not the courage and necessary dexterity to complete the 
 operation, the patients returned with increased sufferings and 
 submitted to a second attempt in which I was successful. In 
 one case I made three attempts to remove the tubes, the third 
 being successful. 
 
 All the patients recovered, and, with two exceptions, are still 
 alive and well. One of these died of English cholera, and the
 
 332 
 
 DISEASES OF THE OVARIES. 
 
 other from acute melancholia, having been allowed to starve 
 herself to death, the folly of her husband standing in the way 
 of her removal to an asylum, where she could have been forcibly 
 fed. 
 
 TWENTY-FOUR CASES OF REMOVAL OF UTERINE APPENDAGES FOR 
 
 HYDROSALPINX. 
 
 No. 
 
 Residence. 
 
 Medical Attendant. 
 
 1 Birmingham ....... Mr. Watkia Williams 
 
 2 Birmingham . . 
 
 3 Birmingham .. 
 
 4 Birmingham . . 
 
 L. T 
 
 L. T 
 
 Dr. Hoare 
 
 Age. 
 
 28 
 
 37 
 
 28 
 32 
 
 5 Redditch Dr. Dodsworfch 39 
 
 6 Stourbridge Dr. Hammond Smith. 27 
 
 7 Walsall Dr. Sharp 37 
 
 8 Birmingham Mr. Hallwright 34 
 
 9 London Dr. T. Chambers , 29 
 
 10 Walsall L. T 38 
 
 11 Warwick Dr. Watson j 33 
 
 12 Warwick Mr. Bullock ' 37 
 
 13 Walsall Dr. Hubbard 32 
 
 14 Birmingham Mr. J. R. Harmar 49 
 
 15 Birmingham Mr. Holbeche 34 
 
 16 Walsall Mr. Willmore 46 
 
 17 Birmingham Dr. Hickinbotham . . . 38 
 
 18 Lichfield Mr. Clay 28 
 
 19 Birmingham Dr. Quirke 34 
 
 20 Birmingham L. T 25 
 
 21 iRedditch Dr. Mathews 20 
 
 23 Coventry Dr. Fenton 39 
 
 23 Birmingham Dr. Sawyer | 40 
 
 24 Wanganui, N. Z. . . . Dr. ConoUy | 23 
 
 M. 
 or S. 
 
 Date. 
 
 1881. 
 
 'july 14. . 
 Aug. 19.. 
 Oct. 7 . . . 
 Oct. 19 . . 
 Oct. 24 . . 
 Nov. 9 . . 
 Nov. 14. . 
 Nov 30.. 
 Dec. 10.. 
 
 M. iDec. 16.. 
 
 I 1883. 
 
 W. Feb. 27.. 
 M. March 7.. 
 M. April 11. . 
 S. May 16 . 
 M. July 13 . . 
 M. Aug. 17.. 
 M. Sept. 5.. 
 M. Sept. 8.. 
 M. Sept. 87. 
 M. Oct. 12... 
 
 1879. 
 
 M. May 23 
 
 1880. 
 
 M. Aprils 
 
 M. Sept. 24 
 
 M. Oct. 5 
 
 Hosp. P 
 
 
 .. P 
 
 
 H. . 
 
 
 H. . 
 
 
 H. . 
 
 
 H. . 
 
 
 H. . 
 
 
 H. . 
 
 
 H. . 
 
 
 H. . 
 
 
 H. . 
 
 . 
 
 H. . 
 
 . 
 
 H. . 
 
 
 H. . 
 
 
 .. P 
 
 
 H. . 
 
 
 H. . 
 
 . 
 
 H. . 
 
 . 1 
 
 H. . 
 
 
 .. P 
 
 
 H. . 
 
 
 H. . 
 
 , 
 
 .. P 
 
 
 .. P 
 
 
 .. P 
 
 
 TWO CASES OF REMOVAL OF OVARY FOR ABSCESS. 
 
 No. 
 
 Residence. 
 
 Medical Attendant. 
 
 Age. 
 
 M. 1 
 or S. 1 Date. 
 
 Hosp. 
 
 P. 
 P. 
 
 R. 
 
 1 
 
 2 
 
 Birmingham 
 
 Wolverhampton 
 
 Mr. HaUwright 
 
 Dr. Lycett 
 
 42 
 
 37 
 
 ■ 1873. 
 
 M. Feb. 11..,. 
 
 1880. 
 
 M. June 28 
 
 1 
 
 R. 
 R. 
 
 H means hospital case. P, private case, R, recovery.
 
 RECENT EXTENSIONS OF ABDOMINAL AND PELVIC SURGERY. 333 
 
 TWENTY CASES OF REMOVAL OF UTERINE APPENDAGE FOR PYOSAL- 
 
 PINX. 
 
 Ko. 
 
 Residence. 
 
 Medical Attendant. 
 
 Age. 
 
 M. 
 
 orS. 
 
 Date. 
 
 Hosp. 
 
 1 
 P. ! 
 
 R. 
 
 1 
 
 Sutton 
 
 Mr. Evans 
 
 26 
 
 37 
 
 28 
 32 
 
 37 
 40 
 29 
 31 
 
 28 
 35 
 27 
 28 
 37 
 49 
 31 
 38 
 28 
 32 
 28 
 27 
 
 M. 
 
 M. 
 M. 
 M. 
 
 M. 
 M. 
 M. 
 S. 
 
 M. 
 S. 
 M. 
 M. 
 W. 
 M. 
 M. 
 M. 
 S. 
 M. 
 W. 
 M. 
 
 1879. 
 Oct. 11 
 
 1880. 
 
 Aug. 3 
 
 Sept. 24 
 
 Oct. 5 
 
 1881. 
 
 March 6 
 
 May 21 
 
 June 13 
 
 Oct. 21 
 
 1883. 
 
 Feb. 2 
 
 Feb. 9 
 
 Feb. 22 
 
 March 4 
 
 March 10 . . . 
 March 13 . . . 
 
 April 12 
 
 April 21 
 
 April 27 
 
 June 28 
 
 June 28 
 
 Aug. 17 
 
 H. 
 H. 
 
 H. 
 
 H. 
 H. 
 
 1 .. 
 H. 
 
 H. 
 H. 
 
 H. 
 H. 
 
 H. 
 
 P. 
 P. 
 
 P. 
 P. 
 
 p! 
 
 p! 
 p! 
 
 p. 
 
 p. 
 
 R 
 
 2 
 
 3 
 4 
 
 Hanley 
 
 Birmingham 
 
 Birmingham 
 
 Church Stretton 
 
 Darlaston 
 
 Cradley 
 
 Dudley 
 
 Birmingham 
 
 Birmingham 
 
 London . , 
 
 Dr. C. H. PhilUps.... 
 
 L. T 
 
 Dr. Hoare 
 
 R, 
 
 R. 
 R 
 
 5 
 
 6 
 7 
 8 
 
 q 
 
 Dr. McLintock 
 
 Dr. Cameron 
 
 Dr. Standish 
 
 Mr. Samuel Berry . . . 
 
 Mr. Green 
 
 R, 
 R. 
 R, 
 R. 
 
 R 
 
 10 
 
 11 
 
 Mr. J. R. Harmar 
 
 R. 
 R, 
 
 19 
 
 Stafford 
 
 Stonehouse 
 
 Wednesbury 
 
 Walsall 
 
 Dr. Day 
 
 t- 
 
 IS 
 
 Dr. Eshelby 
 
 14 
 
 15 
 
 Mr. J. C. Garman.... 
 
 Dr. Holliday 
 
 Dr. C. J. Bracey 
 
 Mr. G. Sharp 
 
 Dr. Lloyd Roberts. . . 
 
 Dr. Evans 
 
 Mr. Briggs 
 
 R. 
 R 
 
 16 
 17 
 18 
 19 
 20 
 
 Birmingham 
 
 Walsall 
 
 Manchester 
 
 Budleigh 
 
 Birmingham 
 
 R, 
 R. 
 R. 
 R. 
 R. 
 
 The gratifying success which has followed these efforts in ab- 
 dominal surgery has induced me to venture into fields hitherto 
 untrodden, or very sparsely traversed, and in these my success 
 has been quite as great. 
 
 The following is a list of operations of various kinds which 
 have directly issued from the great advance in ovariotomy in 
 1878, all of which, with one exception, have been successful : 
 
 Nephrectomy 1 
 
 Nephrotomy 8 
 
 Cholecystotomy for gallstone 4 
 
 Hepatotomy for hydatids of liver 10 
 
 Laparotomy for pelvic abscess 2Q 
 
 Laparotomy for abscess of spleen 1 
 
 Laparotomy for hydatids of peritoneum -t 
 
 Laparotomy for chronic peritonitis 8 
 
 Laparotomy for acute peritonitis 2 
 
 Laparotomy for removal of extra-uterine pregnancy ... 7 
 
 65
 
 334 DISEASES OF THE OVARIES. 
 
 The only fatal case was one of extra-uterine pregnancy with 
 a living child. The mother died of exhaustion, but the child i? 
 now about three years old and is thriving. 
 
 By no means the least satisfactory groups in the above list 
 .are those of acute and chronic peritonitis. In these cases abso- 
 lute cures have been effected, in every instance, by the -simple 
 plan of opening the peritoneal cavity, cleaning it out, and drain- 
 ing it for a short time. That they were cases of an extreme 
 kind might be shown by their details, but probably one will suf- 
 fice. I take the following description of the patient's condition 
 from a letter written to me by Dr. Justin McCarthy, who sent 
 her to me : " The condition in which I found her was one of the 
 greatest emaciation ; seldom have I seen it greater, unless in the 
 last stage of phthisis. There was an enlargement of the abdo- 
 men of rapid growth, and she had incessant vomiting and diar- 
 rhoea.*' I opened the abdomen, cleansed it, and drained it on 
 May 18, 1882, and I saw her five months after, stout and robust, 
 and able to perform any kind of work. 
 
 •In Mr. Spencer Wells' recently published book is given a list of 
 thirty-nine cases of removal of uterine tumor with twenty deaths. 
 This terrible mortality would be more than enough to condemn 
 the operation, and up to a short time ago, in my own practice, the 
 results were nearly as bad, and I did condemn it very strongly. 
 I found, however, from my failures, that it was, as in ovari- 
 otomy, the method of dealing with the pedicle which was at fault, 
 and now that I have altered and amended this, I have obtained 
 results which seem to promise that I shall do almost as well in 
 the removal of uterine tumors as I have done in ovariotomy. 
 
 Of the twenty deaths in Mr. Wells' list, fifteen occurred with 
 the use of the ligature for the treatment of the pedicle, and only 
 •one with the clamp. My experience is quite in harmony with this. 
 I found when I used the ligature, however tightly it was tied, and 
 however carefully I stitched it up like a stump, as advised by 
 Mr. Wells, the stump shrank in a few hours from the escape of se- 
 rum, the ligature loosened, and the patient died of hemorrhage. 
 In only two cases have I been successful with the ligature, and 
 in both I added the cautery, and did not sew up the stump. 
 Therefore, it need hardly be said that my experience is not in 
 favor of Mr. Wells' recommendations ; and it seems to me more 
 than curious to see Mr. Wells deserting the clamp in the very 
 field where its use is promising to be an advance, after he had 
 used it for twenty years in a field where it was a detriment and 
 a hinderance to all progress. 
 
 I do not gather from his writings that in the cases where 
 he employed the clamp, that it was other than the old caliper
 
 KECENT EXTENSIONS OF ABDOMINAL AND PELVIC SURGERY. 335 
 
 form, the use of which he made familiar. He seems to have 
 used it in six cases, of which only four recovered, which is much 
 better than his results with the ligature, for with that treatment 
 of the pedicle he had fifteen deaths and only fourteen recoveries. 
 In my own practice I found that the caliper-clamp was fatal be- 
 cause it was quite impossible to close the abdominal wound accu- 
 rately around the flattened stump, just as in ovariotomy. 
 
 I found that Koeberle's plan was open to objection because the 
 small size of the wire cut the pedicle and gave rise to secondary 
 hemorrhage (in two cases), and that (in one case) the wire broke 
 some hours after the operation and allowed fatal hemorrhage to 
 occur. I therefore devised the clamp which is figured on page 
 285, and which has proved completely successful in every case to 
 which I have applied it, as may be seen from the following list : 
 
 EIGHT CASES OF HYSTERECTOMY FOR MYOMA IN WHICH THE PEDICLE 
 WAS TREATED BY TAIT'S CIRCULAR WIRE CLAMP. 
 
 No. 
 
 Medical Attendant. 
 
 Glasgow . 
 
 Stoke-on-Trent. 
 
 Dr. Bruce. 
 
 Dr. Craig 
 
 Age. 
 
 41 
 
 43 
 
 Ellesmere Mr. J. W. Roe 32 
 
 Liverpool Dr. Graham 32 
 
 Nottingham Dr. Beddard 41 
 
 Birmingham Dr. Hickinbotham 45 
 
 Cheltenham Dr. Gooding 44 
 
 Derby JMr. Wright Baker 38 
 
 M. 
 orS. 
 
 Date. 
 
 Hosp. 
 
 P. 
 
 1880. 
 
 S. 
 
 Sept. 8 . . . 
 
 1881. 
 
 
 P. 
 
 M. 
 
 Nov. 17... 
 
 188^. 
 
 H. 
 
 
 M. 
 
 AprH 23. . . 
 
 
 P. 
 
 S. 
 
 June 13. .. 
 
 
 P. 
 
 M. 
 
 Aug. 5. . . . 
 
 
 P. 
 
 M. 
 
 Sept. 8 
 
 H. 
 
 
 M. 
 
 Sept. 28. . . 
 
 H. 
 
 , , 
 
 M. 
 
 Sept. 28. . . 
 
 
 P. 
 
 R. 
 
 R. 
 
 H means hospital case. P, private practice. E, recovery. 
 
 In one of these cases (4) the responsibility of performing the 
 operation had been declined by Mr. Spencer Wells, and another 
 (7) came to me from the Samaritan Hospital, where she had been 
 under the care of Mr. Knowsley Thornton. 
 
 Cholecystotomy. ' 
 
 Dr. Marion Sims attributes to Dr. Handfield Jones,' and I 
 think correctly, the merit of first suggesting that the liver and 
 
 ' Reprinted from Vol. LXIII. of the Medico-Chirurgical Transactions, published by 
 the Royal Medical and Chirurgical Society of London. 
 
 " Mr. Whitaker Hulke has pointed out that Dr. Handfield Jones' proposal was anti- 
 cipated by Jean Louis Petit (Memoires de I'Academie de Chirurgie, Tome I., p. 155). 
 How curious that so valuable a suggestion should lie dormant for nearly a century and 
 & half !
 
 336 DISEASES OF THE OVARIES. 
 
 gall-bladder should be included within the field of surgical prac- 
 tice more fully than they had been up to that point, and particu- 
 larly that surgical interference should be made in cases where 
 death is threatened from the impaction of a gall-stone. 
 
 To Dr. Marion Sims himself must be given the credit of hav- 
 ing followed out this suggestion with his usual boldness and 
 ability, and he himself points out that the case in which he did 
 it was not successful only because the operation was too long 
 delayed. 
 
 To my good fortune it has fallen to be the first to follow out 
 Dr. Handfield Jones' idea and Dr. Sims' plan successfully. 
 
 Elizabeth M — -, aged forty, was admitted to the hospital on 
 August 18, 1879, having been sent to me by Dr. Abraham Colles, 
 of Bridgnorth, on account of an abdominal tumor. 
 
 She had been married eighteen years, had borne six children, 
 her menstruation had always been normal, and she had enjoyed 
 perfectly good health until the summer of 1878. At that time she 
 began to suffer from severe spasmodic pains in the right side, 
 these being always aggravated by walking or by lifting even 
 slight weights. In September she noticed a swelling at the seat 
 of pain, and this slowly increased. During last winter her pain 
 became much more intense, her appetite failed, she lost strength 
 and fiesh rapidly, and on admission she presented an emaciated 
 and almost cachectic appearance. She also suffered at that time 
 from incessant headache and sickness, and obstinate constipa- 
 tion. The seat of pain was over the right kidney, where there 
 was a heart-shaped tumor, firm and elastic, in which no fiuctua- 
 tion could be detected, and which was extremely tender to the 
 touch. On examination under ether, this tumor was found to 
 be perfectly movable toward each side ; indeed, it could be 
 pushed completely across the middle line to the left side. All 
 round it a note of intestinal resonance could be produced. When 
 pushed over to the left side, its heart-like shape became very 
 apparent, and when it lay on the left side of the vertebral 
 column, with its a.pex directed downward and to the left, its base 
 evidently retained a connection with the right side. 
 
 A careful examination of the urine gave only negative results, 
 though she spoke vaguely of its having been occasionally dark 
 in color, muddy, and deficient in quantity. 
 
 At the consultation held upon the case, a variety of sugges- 
 tions were made for diagnosis, the chief of which were cystic 
 enlargement of a floating kidney, a tumor of the head of the 
 pancreas, and dropsy of the gall-bladder. But na decided diag- 
 nosis was attempted, and my proposal to open the abdomen, and 
 thus ascertain the nature of the tumor, was agreed upon.
 
 EECENT EXTENSIONS OF ABDOMINAL AND PELVIC SURGERY. 337 
 
 On August 23d I opened the abdomen in the middle line to 
 the extent of four inches, the umbilicus forming the centre of 
 the incision. It then became at once evident that the tumor 
 was a distended gall-bladder. I passed the needle of an aspira- 
 tor into the apex, and drew off a quantity of white, starchy- 
 looking fluid, probably amounting to between twelve and fifteen 
 ounces, but I cannot speak positively as to its amount, as it was 
 unfortunately thrown away by a nurse immediately after the 
 operation. I then opened the gall-bladder at the point of punc- 
 ture, so as to admit my finger, and came at once upon a large, 
 round gall-stone, lying loose in the cavity. This I easily re- 
 moved, and on further search I found another of rather larger 
 size, and probably of pear-shape, at the entrance of the duct, 
 impacted in it, and evidently the cause of the dropsical disten- 
 tion of the gall-bladder. The removal of this stone was a matter 
 of very great difiiculty ; in fact, it took a very much longer 
 time to effect than all the other steps of the operation put to- 
 gether. From the long, narrow, funnel-like cavity in which it 
 was lodged, and from the mobility of the bladder, it was very 
 difficult to seize, and when at last I did get hold of it, I found it 
 adherent to the mucous surface. I had then to consider the ex- 
 treme likelihood that in removing this impacted stone I might 
 tear the walls to which it was attached, and thus certainly kill 
 my patient. I therefore performed a very careful and protracted 
 lithotrity, chipping little fragments off the stone regularly all 
 over its exposed surface till I had the satisfaction of lifting out 
 its nucleus. I then passed a blade of a fine pair of forceps on 
 each side of it, and by a gentle squeeze broke up the remainder, 
 and was then enabled to lift it all out. The weight of the stone 
 removed entire is 4. 2 grammes, and that of the fragments I could 
 gather of the broken stone is 2.9 grammes, but of the latter stone 
 as much again must have been lost on the sponges which were 
 packed into the wound during the process of crushing, and upon 
 which I had constantly to wipe my instruments. I washed the 
 cavity out repeatedly, and took every precaution that I could to 
 secure that no fragments were left. I then stitched the wound 
 in the gall-bladder to the upper end of the wound in the abdomi- 
 nal walls by continuous sutures, leaving the aperture into the 
 bladder quite open, and then I closed the rest of the abdominal 
 opening in the usual way. The operation was performed with 
 complete antiseptic precautions, and the anaesthetic employed 
 was ether. 
 
 She rallied from the operation completely in a few hours. I 
 dressed the wound antiseptically the same evening at 11 p.m., 
 and found the dressings stained with healthy bile. In the fur- 
 23
 
 338 DISEASES OF THE OVAEIES. 
 
 ther progress of the case there is very little to report, save that 
 the flow of bile from the wound continued till September 3d, 
 when the dressings were discontinued and zinc ointment was 
 used in their place. The stitches were removed and the wound 
 was completely healed on September 9th, when she began to 
 take solid food, up to that time her diet having been restricted 
 to milk and beef -tea. On the 14th she sat up for the first time, 
 and on the 30th she went home quite restored to health, free 
 from pain and all her former symptoms, and having gained at 
 least fourteen pounds in weight. 
 
 Looking back upon this case, I do not think that a more 
 accurate diagnosis was possible, for there was an entire absence 
 of those symptoms which usually characterize cases of gall- 
 stone. After the operation she told us that one of her neighbors 
 had said to her one day that she thought the patient was jaun- 
 diced, but beyond this no history could be got at of any symp- 
 toms pointing clearly to the true nature of the case. The singu- 
 lar mobility of the tumor was also a most puzzling condition. 
 Fortunately, our advanced practice in abdominal surgery makes 
 our limited powers of diagnosis in such a case of less impor- 
 tance, and I thoroughly agree with Dr. Sims that we should not 
 wait till the approach of almost fatal symptoms puts the diagno- 
 sis in unmistakable fashion, but that " we shall make an early 
 exploratory incision, ascertain the true nature of the disease, and 
 then carry out the surgical treatment that the necessities of the 
 case may demand." 
 
 Since the original publication of this paper I have operated 
 three times for gall-stone, and these have recovered completely. 
 
 Four Cases of Hepatotomy.* 
 
 I.— On August 15, 1880, I was asked by Dr. Thelwell Pike, of 
 
 Malvern, to see a lady. Miss E. G , aged thirty-seven, whose 
 
 illness had the following history : 
 
 Between 1870 and 1872 she broke down in health, suffered 
 from obscure symptoms of which she can now give no very clear 
 account, but which were referred, by three practitioners whom 
 she consulted, to the spine. In 1872 she consulted the late Mr. 
 Garden, of Worcester, who diagnosed some hepatic mischief, 
 but gave no decided opinion. 
 
 In 1873 she had a severe inflammatory attack, the symptoms 
 of which were regarded by her medical attendants as being due to 
 diaphragmatic pleuritis. That illness continued f orT;hree weeks. 
 
 ' Reprinted from the Birmingham Medical Review, October, 1881.
 
 RECENT EXTENSIONS OF ABDOMINAL AND PELVIC SURGERY. 889 
 
 Since then she has never been well, suffering from bilious at- 
 tacks, swollen legs and feet, dyspepsia, inability to walk, and 
 great mental depression. She asserts that the right leg has al- 
 waj'^s been more swollen than the left. 
 
 In 1876 she and her friends noticed an alteration in her size, 
 she had to have her dress let out, her breathing became inter- 
 fered with, and an enlargement on the right side became appa- 
 rent. This increased slowly till 1879, when it was evident that 
 the whole of the right chest and abdomen were enormously in- 
 creased in size, but it was not till February of this year that any 
 attempt at diagnosis seems to have been made, and the opinion 
 then seems to have been that the enlargement was due to malig- 
 nant tumor. In July she came under Dr. Pike's care, and he di- 
 agnosed it as a case of hydatids of the liver, and this diagnosis 
 was confirmed early in August by Sh" William Jenner, who ad- 
 vised the use of the aspirator. Dr. Pike and Mr. Dawson, of 
 Malvern, aspirated the tumor on August 11th, and withdrew a 
 few teaspoonf uls of clear serum, enough to establish the correct- 
 ness of the diagnosis of multiple hydatids, even though they 
 could find no scolices in it. 
 
 "When I saw her on the 15th, I found her in such a condition 
 that it was evident death from suffocation and exhaustion was 
 imminent if relief could not be given. She was propped up in 
 bed to relieve her breathing, and was vomiting incessantly. She 
 was extremely emaciated, had a hay-like odor of her breath, 
 pinched features, and yellow skin, and all the symptoms of ex- 
 treme exhaustion. The hepatic dulness extended from the third 
 rib down to the umbilicus, crossing the middle line to the left all 
 the way for about two inches, and much more at the lower mar- 
 gin. The whole of the right side was occupied by the tumor, no 
 air was entering the right lung, the left was greatly interfered 
 with, and the heart was pushed much over toward the left. 
 Below the right ribs distinct fluctuation could be obtained over 
 the tumor. 
 
 Acting upon the principle which I have already advocated 
 in previous communications to the Society, of opening the abdo- 
 men in all cases of tumors where life was threatened, and of the 
 malignity of which there was no certainty, I had no hesitation 
 in proposing abdominal section in this case. 
 
 Dr. Pike at once concurred in my proposal, and it was readily 
 accepted by the patient and her friends. 
 
 I therefore returned to Malvern the next day (August 16th), 
 and performed the following operation : Dr. Pike gave ether, 
 and I was assisted by Mr. Dawson and Mr. Raffles Harmar. I 
 made an incision four inches long and about two inches to
 
 340 DISEASES OF THE OVAEIES. 
 
 the right of the middle line, beginning at the edge of the ribs,, 
 and inclining slightly inward toward the umbilicus. Having 
 carefully secured all the bleeding points, I opened the perito- 
 neum, and found that there was no adhesion of the liver to the 
 wall, and that I had exposed healthy liver-tissue. Into this I 
 passed a large-sized aspirator needle, and evacuated a few tea- 
 spoonfuls of clear serum, as had been done before. Removing 
 the needle I passed my knife into its track, and made an open- 
 ing large enough for my forefinger. I then found that the layer 
 of liver-tissue was from half an inch to three-fourths thick. I 
 then fixed a pair of Koeberle's catch-forceps on each of the mar- 
 gins of the wound in the liver, and asked my assistant (Mr. 
 Raffles Harmar) gently to draw them up as I enlarged the inci- 
 sion. This I did to the extent of about three inches, and the mo- 
 ment I freed my finger, myriads of transparent globes of all 
 sizes, from a pea to an orange, shot out, covered the table and 
 floor, and were afterward picked off the floor all over the 
 room. When the tension was relieved, I dug them out with a 
 large silver gravy-spoon, an instrument suggested to me by Dr. 
 Pike, and this process took much more time than the whole of 
 the rest of the operation, and during its performance, Mr. Har- 
 mar most skilfully prevented any cysts entering the peritoneal 
 cavity, by keeping the flaps of the liver close against the abdom- 
 inal wound. Finally, I perceived that my gravy-spoon was 
 causing some hemorrhage from the inside of the cavity, which 
 had no kind of lining membrane, and I had to leave a consider- 
 able quantity of cysts in the cavity. In the cut surface of the 
 liver, two bleeding points gave me some anxiety, but I closed 
 them temporarily with Koeberle's forceps, and finally secured 
 them in the stitches. These I applied by a common short 
 needle and piece of silk in the continuous method, fastening the 
 wound in the liver, through the whole thickness of the tissue to 
 the wound in the abdominal wall, so as effectually to close the 
 peritoneal cavity ; I then fastened in a wide glass drainage-tube 
 eight inches long. The quantity of hydatid cysts evacuated, is 
 estimated by Dr. Pike to be about two gallons, and I think the 
 amount is not exaggerated. 
 
 The patient rallied well from the operation, and seemed to 
 suffer nothing from shock. Her sickness ceased immediately 
 after the operation and did not return, and her breathing became 
 at once relieved, so that she could lie flat on her back, or on 
 either side. 
 
 I saw her again with Dr. Pike on the 19th, when I found her 
 without a bad symptom, eating well, entirely free from pain, and 
 with the hepatic dulness contracted to almost normal limits. A
 
 KECENT EXTENSION'S OF ABDOMINAL AND PELVIC SURGERY. 341 
 
 large number of cysts had come through the tube daily with the 
 discharge, which was faintly tinged with bile. Dr. Pike washed 
 out the cavity twice a day with weakly carbolized water. 
 
 I saw her again on September 2d, and found the wound heal- 
 thy, that Dr. Pike had removed the stitches, and that the cavity 
 held only about half a pint. Only one very small cyst had come 
 away since my previous visit. I found also that she was gaining 
 flesh rapidly, and eating well, her diet that day having included 
 bacon, cheese, and porter. 
 
 The daily details of the case possess but little interest, beyond 
 the fact that at the end of the first week a short (three-inch) 
 wide glass tube replaced the long one, and in a fortnight more, 
 a f rubber tube was inserted instead of the glass. Fragments 
 of cysts continued to come away for about a month, and now 
 {October 17th) there has been hardly any discharge at all for a 
 fortnight, and nothing remains but a sinus. 
 
 Dr. Pike notes that one day during the syringing out of the 
 €avity, she had a sharp, sudden pain passing round from right 
 to left. This lasted some three or four hours, and after that 
 about half a pint of bile was passed from the wound, and the 
 pain gradually ceased. 
 
 The patient herself writes to me that she feels now quite 
 well, and is able to walk about alone, not quite eight weeks af- 
 ter the operation. She is now (1882) in perfect health and has 
 married. 
 
 II. — J. D , aged fifty-six, was seen by me for the first time 
 
 on February 5, 1881, in consultation with Dr. G. P. Hadley, of 
 Lozells, under whose care, in conjunction with Dr. Heslop and Dr. 
 B. Foster, he had been for some months. Dr. Hadley has favored 
 me with the following notes : He saw J. D. for the first time in 
 August, 1879, when he had an attack of severe illness which was 
 regarded as due to the passage of a gallstone. In January, 1880, 
 a large tumor was discovered occupying the whole of the epigas- 
 trium, right hypochondrium, and extending downward into the 
 right ihac region. The tumor had an indistinct fluctuation. 
 During 1880 the patient became greatly emaciated, passed gen- 
 erally clay-colored stools, and frequently had his urine deeply 
 tinged with bile. In December, 1880, the cyst seemed to find an 
 opening into the intestine, for the tumor became greatly dimin- 
 ished in size, and the patient passed large quantities of brick-red 
 fluid from the rectum. After this discharge the cavity seemed 
 to refill in a few days, and the process was repeated at inter- 
 vals. In January, 1881, the process of emptying seemed to 
 cease, and it was proposed to tap the cyst, but on account of 
 the presence of intestines all over the front of the tumor it was
 
 342 DISEASES OF THE OVARIES. 
 
 deemed more prudent to have an exploratory incision made, and 
 I was asked by his attendants to undertake this. I had no 
 hesitation in doing so, for I found the patient extremely ema- 
 ciated, with a distinct icteric hue, and evidently sinking. There 
 was a very large cystic tumor, apparently belonging to the 
 liver, and on February 6th I performed the following operation, 
 assisted by Mr. Wright Wilson and Dr. Williams, of Dyffrin, 
 the ether being administered by Mr. Bennett, Dr. Hadley's 
 assistant. 
 
 I made an incision about three inches in length over the 
 tumor, in the axis of the right rectus muscle, and about three 
 inches to the right of the middle line, beginning about two 
 inches above the level of the umbilicus. The peritoneum was 
 easily reached, but there I found intestines and omentum glued 
 everywhere over the surface of the tumor, and I had to exercise 
 much care in dissecting them off, so as to clear a part of the 
 cyst about two square inches in area. There was, however, no 
 adhesion between the parietal layer of peritoneum and the sub- 
 jacent intestines. I then passed my small-sized trocar into the 
 tumor, and evacuated seven and a half pints of dark, bilious- 
 colored fluid. Wiien the cavity was emptied completely, I en- 
 larged the opening made by the trocar so as to admit two fingers, 
 and came at once upon a loose mass, which I removed, and 
 which proved to be a slough of liver-tissue weighing about one 
 ounce. I then stitched the edges of the wound in the liver to 
 those of the wound of the abdominal wall, and fixed in a glass 
 drainage-tube. The cyst was clearly the liver itself, which had 
 been distended into a shell, with apparently a pretty vmiform 
 thickness of about half an inch. The fluid removed was care- 
 fully examined by Dr. Saundby, the Pathologist to the Women's 
 Hospital, and found to consist of nearly pure bile, mixed with 
 pus. 
 
 The progress of the case must be given briefly, for there is 
 very little to tell. No effort was made to conduct the treatment 
 upon Mr. Lister's principles. The glass drainage-tube was left 
 in for about a fortnight, and then a piece of rubber tube replaced 
 it. The temperature and pulse curves were almost normal, the 
 patient's appetite rapidly improved, and upon my last visit to 
 him (March 30th) there was very little discharge from the 
 drainage-tube, and he had gained fourteen pounds in weight in 
 the seven weeks which had elapsed since the operation. (P.S. — 
 He has gained forty-two pounds since the operation, September 
 16th.) 
 
 III. — L. B , aged twenty-five, was placed under my care 
 
 by Dr. Thompson, of Leamington, who had recognized the
 
 KECENT EXTENSIONS OF ABDOMINAL AND PELVIC SURGERY. 343 
 
 presence of a large abdominal tumor, which caused the patient 
 much distress. She had been married four years, but had never 
 been pregnant. Her illness began with a sudden attack of pain 
 at the seat of the swelling, in September, 1880, and since then 
 the tumor had steadily grown till I saw her in February. The 
 nature of the tumor was doubtful. It was in the position of the 
 right kidney, was movable, but had an attachment above, which 
 suggested an origin from the liver. No distinct fluctuation 
 could be discovered in it. 
 
 On February 9th, assisted by Dr. Thompson and Mr. Raffles 
 Harmar, I made an abdominal section, and found it to be a 
 hydatid tumor of the liver, which had no adhesion to the ab- 
 dominal wall. I opened the capsule, which consisted of a layer 
 of liver-tissue, about a fourth of an inch in thickness, and 
 scooped out the hydatids with a dessert-spoon. They were of 
 various sizes, from a pea to a small orange, and amounted in all 
 probably to a pint and a half or two pints. I was very careful 
 to cleanse out the deep cavity in the liver very thoroughly, and 
 Mr. Harmar very skilfully kept the edge of the hepatic wound 
 up out of the abdomen, so that none of the parasites escaped into 
 the peritoneum. The wound in the liver was stitched to the 
 wound in the abdominal wall, and a glass drainage-tube was 
 fastened in. The after-progress of the case was uninterrupted 
 recovery, no effort being made to conduct its treatment on Mr. 
 Lister's principles. The glass tube was replaced by a rubber' 
 tube at the end of a fortnight, and she returned home to Leam- 
 ington on March 9th, just a month after the operation, and there 
 she is rapidly recovering under the care of Dr. Thompson, the 
 drainage-tube having been removed (April 33d), and the wound 
 is now nearly healed. (P.S. — This patient is now in perfect 
 health, September 16th.) 
 
 IV. — E. P , aged twenty-one, and unmarried, was placed 
 
 under my care by Dr. Wellesley Tomkins, of Leamington, in 
 August last, for an abdominal tumor. This I recognized at once 
 to be an enlargement of the liver, and unhesitatingly made a 
 diagnosis of hydatid disease. Her illness began in April, 1880, 
 with an attack of violent bilious sickness, followed by pain in 
 her back and right side. The enlargement was noticed within 
 six weeks, and had steadily increased. She suffered from re- 
 peated attacks of violent bilious vomiting. The hepatic dulness 
 extended from the fourth rib down to an inch below the level of 
 the umbilicus, and from the spine round to four inches across 
 the middle line in front, and distinct fluctuation could be felt in 
 the tumor below the ribs. I kept the case under observation 
 from August till February, during which period she increased
 
 344 DISEASES OF THE OVAKIES. 
 
 two and a half inches in girth over the lower ribs, and fell ofif 
 markedly in health. I had many consultations with profes- 
 sional friends over the case, more particularly did Dr. Heslop 
 give me valuable assistance. The question, of course, lay be- 
 tween aspiration and hepatotomy, and this could be decided 
 only by our being able to recognize which of the two varieties 
 of hydatid disease my patient suffered from. 
 
 No indication of this could be obtained, and having a lively 
 recollection of the disastrous effect of aspiration in a case 
 already published by the Royal Medico-Chirurgical Society, and 
 further, having a growing distrust in aspiration for abdominal 
 surgery, and an increasing confidence in abdominal section, I 
 determined upon the latter. I therefore proceeded similarly as 
 was done in the other cases. It turned out to be a large mono- 
 cystic hydatid. The thickness of liver-tissue through which I 
 passed was nearly an inch, and I had a little trouble with 
 hemorrhage, which was, however, completely controlled by 
 pressure. I fixed in a wire drainage-tube, after having united 
 the edges of the two wounds, and replaced it by a soft rubber 
 tube at the end of a fortnight. This latter tube I finally re- 
 moved on April 13th, and on the 19th the wound was almost 
 healed, the patient was getting about, eating wall, and rapidly 
 gaining strength. Possibly, in this case it might have been 
 better to have tried aspiration first, and that may be the opinion 
 of some. I do not agree with this, however, and I see no reason 
 to regret my action. I am growing more and more satisfied 
 that all such cases will be the best treated by abdominal section. 
 (P.S. — This patient, also, is now in perfect health. I have 
 operated upon six other cases of hydatids of the liver in exactly 
 the same way, and all have done well, September 16, 1882.) 
 
 The Treatment of Pelvic Suppuration by Abdominal Sec- 
 tion AND Drainage.* 
 
 I have purposely used the words ''pelvic suppuration" in 
 the heading of this paper, in order to advocate a principle which 
 I believe to be capable of a much wider application than it has 
 already had at my hands. The cases, six in number, in which 
 I have pursued this new method of treatment have all been, so 
 far as I could discover, cases of suppuration occurring in pelvic 
 heematoceles ; but the difficulties in these cases have been no 
 greater than I think would occur in pelvic suppuration of almost 
 
 ^ Reprinted from Vol. LXIII. of the Medico-Chirurgical Transactions, published 
 by the Royal Medical and Chirurgical Society of London.
 
 RECENT EXTENSIONS OF ABDOMINAL AND PELVIC SUEGERY. 345 
 
 any kind, and the success has been most exceptionally encourag- 
 ing. My experience is, of course, limited to suppurations of the 
 female pelvis, but I see no good reason why the same proceed- 
 ings should not meet with equal success in some cases, at least, 
 ■occurring in the male. 
 
 Like others who follow the surgical specialty in which my 
 practice lies, I have had a wide field for the observation of the 
 various conditions classed under the head of pelvic abscess, and, 
 like others, I have until recently confined my treatment of it to 
 openings made from the vagina or in the neighborhood of Pou- 
 part's ligament. Experience, however, has driven me to the 
 conclusion of Dr. Emmet, that " I cannot regard the introduc- 
 tion of the trocar into the inflamed tissues of the pelvis as a 
 procedure free from danger under all circumstances." It is per- 
 fectly true that in very many cases where an abscess undoubt- 
 edly exists in the cellular tissue of the female pelvis, the fluid 
 can be reached and removed by the needle of the aspirator. 
 But, according to my experience, the relief obtained in this way 
 is, in a large number of cases, neither complete nor permanent, 
 and, in nearly all, the convalescence has occupied a time not at 
 all commensurate with the extent of the lesion. This is quite as 
 true of abscesses which have been allowed to open themselves, 
 or have been assisted to open in the groin. They often continue 
 as fistulous openings for years. 
 
 In many cases, even when the abscess can be reached by 
 vaginal puncture, the nature of its contents is such as to make 
 its evacuation an impossibility ; and I have seen several where 
 a puncture made at random through an indurated pelvic roof 
 has missed the disease. In these cases the symptoms of the 
 presence of pus were conclusive, but no indication of its seat 
 could be obtained. Dr. Emmet speaks of such in these words : 
 ' ' I can recall a number of cases which have been under m}* 
 observation, with thickened tissues, where no treatment ha(\ 
 the slightest effect, and finally, they have passed into other 
 hands." 
 
 The course of such abscesses is so thoroughly described by 
 Dr. West that his words cannot be improved upon, and therefore 
 I give them at length : 
 
 "When suppuration takes place, the matter makes its way 
 outwardly through the vagina, or through the intestinal canal, 
 in almost all cases in which the inflammation is limited to the 
 parts contained within the broad ligament. In those cases, 
 however, in which the pelvic cellular tissue is implicated, the 
 matter not unfrequently makes its way round between the mus- 
 cles and the external surface of the peritoneum, and the abscess
 
 346 Diseases of the ovaries. 
 
 points and discharges itself through the abdominal walls some- 
 where in the course of Poupart's ligament, or a little below that 
 situation. 
 
 " Though the size of the abscess is not, in general, very 
 great, it not unfrequently passes into a chronic state, and 
 emptying itself, for the most part, through some narrow passage 
 of communication into the bowel, the patient continues for 
 months or years liable to occasional discharges of pus per anum, 
 the commencement of which dates back to some attack of in- 
 flammation of the cellular tissue years before." 
 
 In an instance quoted by Dr. West, " occasional discharges 
 of matter took place from the bowel, and pus was often inter- 
 mixed with the faeces, five years after the first symptoms of in- 
 flammation of the cellular tissue about the uterus, the chronic 
 results of which were still evident in a tumor which was closely 
 connected with the rectum and the womb. These chronic ab- 
 scesses generally contract, and the fistulous passages that lead 
 to them become, by degrees, obliterated, but exceptions to this 
 now and then occur, two of which have come under my own 
 notice ; and Sir J. Simpson has reported some very interesting 
 cases where permanent fistulous communications have formed 
 between the abscess succeeding to inflammation of the pelvic 
 cellular tissue and the bladder, uterus, or intestinal canal." 
 
 In my own practice such disappointing cases have occurred 
 with but too great frequency, and though I have had some suc- 
 cesses by the employment of such means as the elastic ligature 
 {Lancet, June 27, 1874) and counter-opening in the vagina {Lan- 
 cet, April 3, 1875), yet the progress toward recovery has been so 
 protracted as to contrast favorably only with those cases in 
 which there was no recovery at all. 
 
 I have been, therefore, continually on the outlook for some 
 means of dealing with such cases which would bring them as 
 satisfactorily within our means of treatment as are collections 
 of matter in most other parts of the body. This has been fur- 
 nished by the wide, free, and successful application of abdomi- 
 nal section for the treatment of pelvic and abdominal tumors, 
 and I have now to lay before the Society six cases, which include 
 the whole of my experience in this novel proceeding, and in 
 which success has been obtained far surpassing anything I have 
 yet seen or heard of. In this comparison I am of course exclud- 
 ing those cases where pointing of the abscess in the vagina is 
 evident at an early stage of the case, but even in these the re- 
 covery has always been, in my experience, more protracted than 
 in the six now to be narrated. 
 
 A patient was sent to me in February, 1879, by. Mr. Gwinnett
 
 RECENT EXTENSIONS OF ABDOMINAL AND PELVIC SURGERY. 347 
 
 Sharp, of Walsall, suffering from a pelvic tumor, associated 
 with very severe symptoms. She was twenty-two years of age, 
 and had been married nine months. Her menstruation had 
 always been too frequent and too profuse, and six weeks before 
 I saw her it had stopped suddenly during its course, and this 
 was associated with the onset of violent pelvic pain — one of the 
 leading features of extra-peritoneal hsematocele. A few days 
 afterward she shivered and became very ill and feverish, and 
 these symptoms had become intensified when I saw her ten days 
 after their occurrence. She was then emaciated and hectic- 
 looking, with a high night temperature, intense pain and ten- 
 derness over the lower abdomen, and when examined, a large 
 fluctuating tumor, adherent to and behind the uterus, and going 
 on either side of it, was found to occupy the pelvis and rise about 
 half-way up to the umbilicus. The roof of the pelvis was fixed 
 and hard, and no fluctuation could be felt there. 
 
 The nature of the tumor could be open to only two sugges- 
 tions : that it was a suppurating parovarian cyst with peritonitis, 
 or a suppurating hsematocele. I leant to the latter view, as it 
 was in consonance with the history, and I have never known a 
 parovarian cyst suppurate, whilst hsematoceles frequently do. 
 
 In any case, I determined to open it from above, and this I 
 did. I found a large cavity, containing about two pints of fetid 
 pus with decomposing blood-clots. This I carefully cleansed 
 out, and after having united the edges of the opening into the 
 cyst carefully to the abdominal wound, I fixed in one of Koeber- 
 le's glass drainage-tubes, five inches long. Seven days after the 
 operation I placed a three-inch glass drainage-tube, and in an- 
 other week this was replaced by a soft rubber tube. The patient 
 got up on the twentieth day after the operation, and in ten 
 days more went home perfectly well, with the abscess healed^ 
 and she remains now in perfect health (March, 1880). 
 
 The second case was sent to me by Dr. Flynn, of Birchills. 
 She was forty-five years of age, and had never been pregnant, 
 save one doubtful miscarriage soon after marriage, nineteen 
 years ago. Symptoms resembling those of hsematocele had 
 occurred eight months before I saw her, and since that time she 
 had been losing flesh, had lost her appetite, was troubled by 
 constant thirst and night-sweats, and she had a rising night 
 temperature. The uterus was fixed in a mass of effusion occu- 
 pying the left broad ligament, and partly the right one also, and 
 the mass on the left side encircled the rectum, forming a pro- 
 nounced stricture, as hsematoceles of the left broad ligament 
 frequently do. No point of fluctuation could be felt in the pel- 
 vis, but the symptoms pointed clearly to the presence of pus. I
 
 848 DISEASES OF THE OVAEIES. 
 
 therefore determined to open the abdomen, and readily obtained 
 the consent of my colleague to this proceeding. 
 
 On reaching the peritoneum the two layers were found to be 
 adherent, so that the cavity was not opened. A large abscess 
 was opened just behind the base of the bladder, between which 
 and the uterus it principally lay, but stretching round behind 
 the rectum. The floor and posterior wall of the abscess were 
 found to consist of organized blood-clot, so that its origin was in 
 a blood effusion into the broad ligament. A glass drainage- 
 tube was inserted, and this was changed for one of Chassaig- 
 nac's wire tubes on the eleventh day after the operation. She 
 sat up on the twenty-first day after the operation, and the tube 
 was finally removed on the twenty-sixth. She went home on 
 the thirtieth day perfectly well, and has remained so ever since, 
 now nearly ten months. 
 
 The third case was a patient of Mr. Hallwright's, in whom 
 he had, diagnosed hsematocele some four weeks before I saw 
 her. Symptoms of suppuration set in, and I performed exactly 
 the same operation as in the first case, that is, the peritoneum 
 was opened, and the abscess emptied and cleansed, and then 
 the edges of its opening fastened to the edges of the parie- 
 tal wound, and a glass drainage-tube fastened in. This case 
 also was an undoubted hsematocele of the broad ligament. Eight 
 days after the operation the glass tube was changed for a wire 
 one, and this was removed in twelve days more. She left the 
 hospital perfectly well, only thirty-three days after her admis- 
 sionj and has since remained in good health. 
 
 Mary Ann B , aged thirty, has been married eight years, 
 
 and has had four children, youngest fifteen months old. Seen 
 first by Mr. Hallwright on December 12th, when she stated 
 that she had become unexpectedly unwell about five weeks ago, 
 that this was accompanied by violent pain, which has never 
 since been absent. She was seen by Mr. Hallwright, who diag- 
 nosed the occurrence of hsematocele from the presence of a 
 large hard tumor behind the uterus. About a fortnight pre- 
 vious to my seeing her the nocturnal exaltation of temperature, 
 night-sweats, thirst, and increased pain, led Mr. Hallwright to 
 suspect that the effusion was suppurating, and when I saw 
 her I had no difficulty in confirming his opinion. I therefore 
 admitted her to hospital, and on December 22d I performed 
 abdominal section, as I found the intensity of the symptoms 
 increasing, and on examination under ether the mass of the ef- 
 fusion seemed too high up to be opened safely from the vagina. 
 The tumor consisted of a large effusion of blood in process 
 of disintegration, contained in a cavity formed- by the lifting
 
 EECEISTT EXTENSIONS OF ABDOMINAL AND PELVIC SURGERY. 349 
 
 up of the posterior layer of the broad ligament, the rectum 
 being carried up in front of it, together with the large ves- 
 sels of both sides, as high as the bifurcation of the aorta, 
 whilst anteriorly the peritoneum dipped to a most unusual 
 depth, so that had I tapped the tumor from the vagina, I must 
 have gone through the peritoneal cavity. The cyst was opened 
 and emptied, and a drainage-tube fastened in, and the perito- 
 neum closed in the usual way. Her recovery was neither so 
 easy nor so rapid as any one of the others, probably because the 
 cavity was the largest of all, and her condition before the opera- 
 tion was very bad, though another case to be related was, in the 
 latter respect, much worse. The temperature in the present 
 case was 38.4° before the operation, and it rose to 40° on the 
 second day. It did not fall to 37° till the tenth day, December 
 31st. The drainage-tube was removed on January 10th, and on 
 the 17th the wound had perfectly healed, and she left the hos- 
 pital on the 26th. I saw her on February 26th, when she was 
 hardly to be recognized, so astonishing was her restoration to 
 health. From a thin, emaciated, and apparently dying woman, 
 she had been transformed into a perfect picture of health, and 
 she stated that she was able to do her work and get about as 
 well as ever she did in her life. 
 
 In this case I am quite satisfied that the delay of the opera- 
 tion for a few days would have been fatal, and no vaginal tap- 
 ping, even if it had missed the peritoneal layers, would have 
 emptied the cyst of its clotted contents. 
 
 Ann S , aged twenty-eight, placed under my care in Jan- 
 uary, 1882, by Dr. Gordon, of Walsall. She is the mother of 
 three children, the youngest being three years of age. About 
 four months ago she had symptoms resembling those of sud- 
 den effusion of blood into the broad ligament. For a month 
 she was able to get about, but during the last three months she 
 has been entirely confined to bed, the subject of symptoms 
 clearly pointing to the occurrence of suppuration. Dr. Gordon 
 had discovered the presence of a pelvic mass behind the uterus, 
 in which no fluctuation could be discovered, and which was 
 fixed. 
 
 I admitted her into hospital, and suspecting the case to be 
 one of suppurating hsematocele, I opened the abdomen on Janu- 
 ary 5th, and found the case to resemble the preceding one, save 
 that the disintegrating effusion was not so large. It was dealt 
 with in the same way, and the patient made a much more easy 
 and rapid recovery, leaving the hospital on January 17th, and 
 being restored to perfect health before the end of February. 
 
 Mrs. H , aged twenty-nine, was married at eighteen, had
 
 350 DISEASES OF THE OVAKIES. 
 
 a child within the year, and has never been pregnant since. I 
 saw her, at the request of Dr. Millington, of Wolverhampton, 
 under whose care she had been, in conjunction with Dr. Black- 
 ford, of Cannock, whom I met in consultation over the case on 
 the 15th of January, 1882. The history given to me was that 
 about nine weeks previously, when driving in an open carriage 
 with her husband on a very cold day, and during a menstrual 
 period, she was suddenly attacked by a violent pelvic pain, and 
 coincidently with this the discharge ceased. This pain had con- 
 tinued ever since, and had of late increased in severity. Men- 
 struation had occurred at two irregular intervals since the 
 beginning of her illness with great profuseness, and during 
 these periods her pain nad been much easier. A pelvic tumor 
 had been discovered by Dr. Millington some weeks before my 
 visit, and this he had regarded as an effusion of blood. She had 
 suffered for about three weeks before I saw her from night- 
 sweats, almost constant sickness, utter loss of appetite, intense 
 thirst, with various other symptoms of pronounced hectic. The 
 tumor, when I examined it, involved all the pelvic organs in a 
 fixed mass of cartilaginous hardness, with the uterus embedded 
 in it ; the bladder spread over it in front, and the rectum en- 
 circled by a ring of hard effusion. The mass could be felt above 
 the pelvis as a round and non-fluctuating tumor, with intestine 
 in front of it. The patient had reached almost the final stage of 
 exhaustion and emaciation. There was no difficulty in diagnos- 
 ing the case as one of suppurating hsematocele. With Dr. 
 Blackford's concurrence we had her removed to Birmingham, 
 and on the 21st I opened the abdomen and found matters quite 
 as I had anticipated. The posterior layer of the broad ligament 
 was lifted completely up out of the pelvis, and so was the an- 
 terior layer, as far as I could make out ; at least, the only struct- 
 ure I could identify was the base of the bladder, and that 
 seemed to form the anterior boundary of the tumor. From this 
 point it spread backward, on a level with the brim of the true 
 pelvis, and its posterior boundary was the bifurcation of the 
 aorta. The contents were clearly fluid, and therefore I tapped 
 it with an aspirator needle, and evacuated about half a quart 
 bottle full of curdy blood-colored piis. I then laid the cyst open 
 from the point of puncture, in a direction from before backward, 
 and found its floor to consist of a thick layer of laminated clot, 
 hard and rigid. I could make out the uterus rising out of this 
 mass, but I could not discover the rectum. 
 
 1 stitched the edge of the opening into the abscess to the 
 edges of the parietal wound, and then closed the rest of the 
 peritoneal opening, and fastened in a wide drainage-tube of
 
 KECENT EXTENSIONS OF ABDOMINAL AND PELVIC SUKGEKY. 351 
 
 glass. After the operation the patient's temperature never rose 
 above 37°, she had no more night-sweats nor sickness, and her 
 appetite was really keen on the third day. A small-sized wire 
 drainage-tube replaced the glass one on the twelfth day, as the 
 discharge had become healthily purulent and free from clot 
 debris. The smaller drainage-tube was removed on the fifteenth 
 day after the operation, and on the twenty -fourth the sinus was 
 quite healed, she had gained greatly in flesh and color, she was 
 able to walk about, and on the twenty-seventh day she went 
 home perfectly well, the uterus, however, being still quite fixed, 
 as I expect it will remain for years, I have just had a letter 
 from her (March 30th), in which she reports herself as being in 
 perfect health. 
 
 In all of these cases I am satisfied that vaginal tapping 
 would have been useless. In most of the cases, if the abscess 
 had been opened by natural processes, it would have been into 
 the rectum. In the last case it would probably have been in one 
 of the groins ; but I think in every one of the cases, unless it be 
 in the second, death would have occurred long before a natural 
 outlet could have been established. 
 
 My general conclusion from these cases is that the opening 
 of such abscesses by abdominal section is neither a difficult nor 
 a dangerous operation ; that recovery is made in this way more 
 certain and rapid than in any other ; and that in future I shall 
 always advise an exploratory incision where I am satisfied there 
 is an abscess which cannot be reached nor emptied satisfactorily 
 from below. 
 
 Since the original publication of this paper I have operated 
 on fifteen cases, and the recovery in all the twenty has been 
 complete and permanent.
 
 INDEX. 
 
 Abdomen, law for exploration of, 333 
 Abscess of ovary, 100, 135, 333 
 
 of spleen, successfully treated, 
 335 
 
 pelvic, treated by abdominal sec- 
 tion, 333, 344 
 Absence of ovaries, 36 
 Accessory or additional ovaries, 9 
 Acute ovaritis, 88, 100 
 Adhesions, 383 
 
 After-treatment in ovariotomy, 307 
 Air in ovarian cysts, 194 
 AlgEe, reproduction in, 3 
 AnEesthetic, selection and administration 
 of, 363 
 use of, for diagnosis, 195 
 Anatomy of ovary and oviduct, 6 
 Animals, phantom tumors in, 305 
 Anther, 3 
 
 Antiseptic system, so-called, 368 
 Aphides, reproduction in, 3 
 Appendages, uterine, removal of, for hem- 
 orrhage, 115, 153, 335, 339 
 Arteries of ovary helicoid, 38 
 Ascites, diagnosis of, 168, 197, 318 
 Ass, phantom tumor in, 305 
 Auscultation of ovarian tumors, 196 
 Axial rotation of ovarian tumors, 395 
 
 Balleray, Dr , on hernia of ovary, 50 
 
 Ballottement, 199 
 
 Bantock, Dr. , on Listerism, 376 
 
 Battey, Dr., on " normal ovariotomy," 336 
 
 Boll, John, on ovariotomy, 343 
 
 Bimanual examination, 193 
 
 Biology, elementary instruction in, 3 
 
 Broad ligament, 0. 13 
 
 Bronchitis from ether, 366 
 
 Brown, Mr. Baker, 146, 346 
 
 Bulb of ovary, 7 
 
 23 
 
 Cancer, a reversion of type, 140, 147 
 
 of peritoneum, 318 
 Carbolic acid poisoning, 310 
 Cartilage in tumors, 158 
 Castration of vromen, 336 
 Catheter, caution in using, 313 
 Cautery, Baker Brown on, 346 
 Caution in use of sound, 193, 300 
 Chad wick, Dr. J. R., on rupture of Fallo- 
 
 plan tube, 67 
 Cholecystotomy for gall-stone, 333, 335 
 Chronic ovaritis, 43 
 Cirrhosis of ovary, 107 
 Clamp, a retrograde step, 348, 353 
 high mortality of, 353 
 Tait's twin, 384 
 use of, for uterine tumors, 316 
 Clay, Charles, 344, 351 
 Cleausing out peritoneum, 389 
 Climacteric growth of omental fat, 308 
 Colica scortorum, 93 
 Contractions of uterus, rhythmic, 311 
 Corjius luteum, 30 
 Creighton's views, 33 
 Crib-biting, 306 
 Cystic disease in infants, 30 
 Cystitis after ovariotomy, 313 
 Cystoma and myoma, connection between, 
 causing hemorrhage, 116 
 
 hemorrhagic, 163 
 
 origin of, 137, 143 
 
 parovarian, 164 
 
 structure of, 154 
 Cysts, extra peritoneal, 184 
 
 Dentigenous cysts, 179 
 Dermoid cysts, parthenogenetic develop- 
 ment of, 31, 178, 183 
 tumors, 175 
 
 contents of, 175
 
 354 
 
 INDEX. 
 
 De Sinety and Melassez, discovery of, 141 
 
 Diagnosis of ovarian and parovarian tu- 
 mors, 168 
 
 Discus proligerus, 29 
 
 Dislocation of ovaries, 40 
 
 Doran, Mr. Alban, on history of ligature, 
 286 
 
 Drainage of peritoneum, 290, 314 
 
 Duncan, Dr. Mathews, on chronic ovari- 
 tis, 111 ; on ovariotomy, 157; on my- 
 oma, 324 
 
 Dysmenorrhoea, 89 
 
 Education of girls, 91 
 
 Enucleation of tumors, 157, 288 
 
 Epiblast, 15 
 
 Epilepsy, menstrual, 107, 328 
 
 Epithelium, changes of intracystic, 143 
 
 ciliated, 144 
 
 cystic, 144 
 
 follicular, 18 
 Ergotin, use of, 90 
 Ether, how to give, 263 
 Evolution, law of, 2f> 
 
 of genital organs, 11 
 Examination by vagina, 195 
 Exanthematic atrophy of ovaries, 37, 107 
 
 ovaritis, 100 
 Excess, marital, 92 
 Exploratory incision, 253, 317, 323 
 
 preferred to tapping, 
 202 
 Extraperitoneal cysts, 154 
 Extra-vxterine pregnancy, 74, 227 
 
 Fallopian tube, anatomy of, 13, 33 
 
 muscular hypertrophy 
 
 of, 74 
 physiology of, 33 
 potency of, 71 
 pregnancy in, 74 
 relations of, 6 
 rupture of, 06 
 
 Fibrocystic tumor of uterus, 215 
 
 Fibroma, 158 
 
 Fishes, ovaries of, 10 
 
 Fluctuation, 196 
 
 Follicles, formation of, 19 
 
 Forceps left in the abdomen, 259 
 
 Fremitus, hydatid, 196 
 
 Gaertner's canals, 12 
 Galvanic pessary, 40 
 Genu-pectoral position, 45 
 Germinal epithelium, 15 
 Germs have no influence, 271 
 Germ theory, 272 
 Graafian follicles, 21 
 
 H.ematosalpinx, 57, 69 
 
 Hemorrhage from diseased ovaries, 115, 
 
 from uterine myoma, 824 
 Hemorrhagic cysts, 163 
 Henning's table, 4 
 Hepatotomy, 338 
 Hermaphroditism, 128 
 Hernia of ovary, 47 
 History of ovariotomy, 238 
 
 of tumors deceptive, 189 
 Hospital mortality, 271 
 
 patients, differ from private pa- 
 tients, 114 
 Houston, Robert, history of, 239 
 Hunter, John and William, on ovariotomy, 
 
 242 
 Hydatids of liver successfully removed, 226 
 
 of peritoneum, 189, 220 
 Hydramnios, 190, 195, 213 
 Hydrometi-a, 213 
 Hydroperitoneum, 219 
 Hydrosalpinx, 55, 331 
 
 repeated rupture of, 113 
 Hyperasmia of ovaries, 88 
 Hypererchesis, 55, 103, 130, 177, 180, 182 
 Hyperplasia of ovai'ies, 122 
 Hypertrophy of ovaries, 115 
 Hysterectomy, 324, 334 
 
 Ice-cap, use of, unnecessary, 307 
 Incomplete operations, 317 
 
 often cure, 222, 254 
 Infundibulum, 18 
 Intermenstrual pain, 125 
 Intracystic growths, 142 
 Iron, som».-iiimes dangerous as a remedy, 114 
 
 Keith, Dr. Thomas, on Baker Brown, 246; 
 low mortality with ijautery, 249-323 ; 
 on drainage, 249, 290, 315 ; on spong- 
 ing, 202, 289 ; on Listerism, 280
 
 INDEX. 
 
 355 
 
 Kidney, movable, 228 
 
 cysts of, cured by drainage, 224 
 successful removal of, 224, 318 
 
 K0EBERL6, M., 167, 249; his forceps, 258 
 
 Ligature, disappearance of, 288 
 long, Charles Clay, 246 
 short, Nathan Smith, 243, 286 
 Listerism, 250, 255, 2o8, 273, 280, 307, 309 
 Liver, hj-datids of, successfully removed, 
 226, 333, 338 
 abscess of, 333, 338 
 Lizars, John, 243 
 
 Malpigiiian bodies, 15 
 Marital excess, 92 
 McDowell, Ephraim, 242 
 McMunn, D. , spectroscopic researches, 168 
 Menstruation apparently useless, 25 
 dependent on tubes, 25 
 independent of ovulation, 
 
 25, 33 
 in ovarian disease, 190 
 Mesentery, cysts of, 222 
 Mesoblast, 15 
 Mesovariura, 27 
 Metro-peritoneal fistula, 200 
 Microscopic research, methods of, 155 
 Miliary cancer, 155 
 Miner's enucleation, 157, 288 
 Mullerian duct, 11 
 
 Muscular elements of cyst-walls, 156, 169 
 Music, influence of, 90 
 Myoma, associated with cystoma, 115 
 
 hemorrhage from, 324 
 
 of uterus, 216 
 
 oedematous, 217 
 Myxoma, 153 
 
 Nephrectomy, 333 
 Nephrotomy, 333 
 iTerves of ovaries, 9 
 
 Obsolescence of follicles, 23 
 
 (Edematous myoma, 217 
 
 Oogonium, 3 
 
 Oophorectomy, 326 
 
 Oospore, 3 
 
 Osteoma, 162 
 
 Ova, majority of, fall into peritoneum, 30 
 
 Ovarian pregnancy, 226 
 Ovaries, abscess of, 100, 125, 323 
 absence of, 36 
 accessory, 9 
 arteries of helicoid, 28 
 at puberty, 25 
 
 calcareous degeneration of, 162 
 cancer of, resembles foetal growt 
 
 140, 147 
 defects of, 36 
 development of, 15 
 dislocation of, 40 
 foetal, 16 
 
 follicular hypertrophy of, 115 
 hernia of, 47 
 hypergemia of, 88 
 hyperplasia of, 115, 122 
 of fishes, 10 
 position of, 5 
 posterior surface of, 6 
 removal of, does not unsex, 92 
 size and position of, 4 
 symmetry of, 4 
 tubules of, 16 
 tunica albuginea, 17 
 weight of, 5 
 Ovariotomy, statistics of, 319 
 • preparations for, 257 
 
 instruments for, 258 
 details of, 280 
 under difficulties, 291 
 during pregnancy, 293 
 peritonitis, ii94 
 origin of, 238 
 normal, 326 
 who is to do it ? 256 
 an objectionable word, 184 
 not to be done in general hos- 
 pitals, 254 
 Ovaritis, most frequent on left side, 9 
 chronic, 42, 94 
 acute, 88, 97 
 exan thematic, 100 
 Ovulation before puberty, 25, 29 
 
 after climacteric, 25, 33 
 Ovum, maturation of, 34 
 
 dropsical distention of, 184 
 
 Pain, intermenstrual, 125 
 Pangenesis, 177
 
 356 
 
 INDEX. 
 
 Papilloma, structure and origin of, 154 
 
 nature of, two kinds, 147 
 Parovarian cysts, 10-i 
 
 removal of, not ovariot- 
 omy, 165 
 removal of, always suc- 
 cessful, 168 
 Parovarium, 14 
 Parthenogenesis, 31, 178, 180 
 Pathogeuia of cysts, 143 
 Pedicle, treatment of, 284 
 
 by cautery, 286 
 by ligature, 285 
 Pelvic abscess, 344 
 Peritoneum, folds of, in pelvis, 6 
 hydatids of, 230 
 cleansing of, 2S9 
 abnormalities of, 54 
 Peritonitis, cured by abdominal section, 
 
 834 
 Personal experience, a factor in success, 
 
 272 
 Pfliiger, tubes of, 133, 157 
 Phantom tumor, 204 
 Pheasant, ovarian tumor in, 230 
 Pollen, 3 
 
 Potash, salts of, 90 
 Pregnancy, diagnosis of, 210 
 Fallopian, 74 
 ovarian, 226 
 spurious, 204 
 Priestley, Dr., on intermenstrual pain, 125 
 Prolonged operations very fatal, 283 
 Pseudo-cyeais, 204 
 Puberty, accession of, 87 
 
 ovaries at, 25 
 Pulse curves, 279 
 Pyosalpinx, 57, 61, 331, 333 
 
 Rectum, examination by, 194 
 Reversions of type, 11 
 Rokitansky's tumor, 139, 141, 169 
 Rosenmiiller, organ of, 12, 167 
 
 Samakitan Hospital, misstatements con- 
 cerning, 250 
 Sense of resistance as a sign, 199 
 Signs of ovarian tumor, 192 
 Simon's method of rectal examination, 194 
 Sims, Dr. Marion, 152 
 
 Sound, a dangerous instrument, 193, 200, 
 
 01 o 
 
 perforation of uterus by, 200 
 Spaying of women, 326 
 Spectroscopic examination of cystic 
 
 fluids, 168 
 Spermatic artery, 7 
 
 vein, 7 
 Spleen, abscess of, 333 
 
 enlarged, mistaken for ovarian 
 tumor, 225 
 Sponges, extreme care required with, 261 
 
 prepai-ation of, 262 
 Staffordshire knot, 286 
 Statistics, 319 
 Sterility, 21 
 Stitches, 291 
 
 Struggle for existence, 26 
 Suppuration of ovarian tumors, 306 
 Symptoms of ovarian tumor, 191 
 
 Tapping by vagina, 203 
 
 dangers of, 202, 320 
 
 of hydramnios, disastrous, 213 
 
 ought to be discarded, 169 
 
 Temperature curves, 279 
 
 Theory of cystoma, author's, 140, 142 
 
 Therapeutics of ovarian tumors, 252 
 
 Thornton, Mr. Knowsley, 146, 250 
 
 Toilette of the iDcritoneum, 262 
 
 Trocar for tapping, 203 
 
 for ovariotomy, 261 
 
 Tubes, influence of, in menstruation, 26 
 
 Tubo-ovarian ligament, 14 
 
 Tumor, gangrenous or suppurating, 98 
 
 Tumors of ovary : 
 
 adenoid, 136 
 axial rotation of, 295 
 cancer growing after re- 
 moval of, 140, 148 
 cancerous, 130 
 cartilage in, 158 
 classification of, 133 
 colloid, 152 
 containing ova, 139 
 dermoid, 175 
 diagnosis of, 188 
 fibromatous, 158 
 fluid contents of, 168 
 in infants, 20, 134
 
 INDEX. 
 
 357 
 
 Tumors of ovary : in old women, 135 
 
 malignant fibroma, 160 
 myxomatous, 153 
 origin of, 135 
 osteoma, 163 
 Rokitansky's, 139, 169 
 structure of cystomatous, 
 
 154 
 suppuration of, 806 
 unilocular, never occur, 
 136 
 
 Tympanic corona, 194 
 
 Ukachus, cysts of, 188 
 
 Uterine appendages, removal of, 66 
 
 myoma, 216 
 Uterus, cystic tumor of, 195, 215 
 infantile, 37 
 
 perforation of, by sound, 200 
 rhythmic contractions of, in preg- 
 nancy, 211 
 
 Varicocele, frequent in left side, 7 
 Veins, ovarian, peculiarities of, 9 
 
 Wandering ova, grovpth into tumors, 182 
 
 Wells, Mr. Spencer, 137, 194, 250; use of 
 clamp, 247, 248 ; his high mortality'. 
 247, 248, 251, 322, 334; statements 
 concerning Charles Clay, 250-252; his 
 statistical method. 251 ; his precau- 
 tions, 255 ; on Listerism, 255, 273. 
 276 ; his anesthetic, 262 ; his vivisec- 
 tions, 291 ; hysterectomy, 334 
 
 Wiltshire, ovariotomy during peritpnitis, 
 294 
 
 Wolffian body, 11 
 duct, 11 
 
 Wounds, dressing of, 291 
 
 Zoospore, 2 
 Zygospore, 3
 
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