ligament will set up an inflammation in one or more of these embryonic tubes. If one only be inflamed, a single broad ligament cyst will be produced; if more become distended, a multiple cyst is the result. Most women who have suffered infection after abortion and labor will in time develop one or more such cysts of greater or less size. As the cysts grow they spread apart the folds of the broad ligament. They have no pedicles. At first, while small and if situated far out in the ligament, they can be moved with the ovary and tube; but when they have grown to touch the side of the uterus, they are always sessile upon the uterus. Their sacs are exceedingly thin and are easily ruptured. The fluid in them is perfectly clear, watery, and of a pale straw color. It is entirely innocent and devoid of harmful properties. Sometimes these tumors are of large size, reaching even to the umbilicus. In growing they displace the uterus laterally. They are never of acute formation, but are of gradual growth.

Symptoms. Whatever distress attaches to fixity of the uterus and, if the tumor be large, to the presence of a mass, accompanies these growths. There is not the pelvic pain, nor the fever, nor the recurrent inflammation which accompany pus in the pelvis. The history is usually that of a mild degree of infection following abortion or labor. Upon examination there is felt upon one side of the uterus a very fluid tumor, but slightly sensitive. The uterus is firmly fixed to the tumor and may be pushed away from the tumor to one side only. The arch of the base of the broad ligament upon the side of the tumor is destroyed, and the finger when swept away from the cervix on the tumor side appreciates that the tumor and uterus are but one mass. This is an invariable sign of all broad ligament growths, whether fluid or solid, whenever they reach the side of the uterus. By repeated attacks of peritonitis, purulent foci in the ovary and tube may imitate this relation; but such lesions commonly occupy a position further behind the uterus. ligament abscess causes the general symptoms of pus, while ruptured ectopic gestation and broad ligament.

Broad

fibroid are much firmer. The marked fluidity, the thinness of the walls, and the clinical history will usually make the diagnosis clear.

Treatment. If the growths are small and purely pelvic in location, they are easily treated through the cul-de-sac. But where they are large and extend above the pelvic brim they should be removed through the abdomen. Upon opening the cul-de-sac the diagnosis is easily made. A gauze pad is introduced into the pelvis above the tumor, and the head of the table lowered. The anterior trowel and posterior retractor readily expose the tumor to view. Its surface is smooth and glistening, and through its thin sac the clear fluid is seen. Having inspected the tumor, enough gauze pads are introduced into the pelvis to keep all intestines above the brim, and the patient is brought to a horizontal position. A pair of closed blunt scissors are shoved into the tumor, and its contents escape through the vagina. It is the posterior layer of the broad ligament which is punctured by the scissors. As the scissors are withdrawn the blades are opened so as to make a wide rent in the sac. The pelvis is wiped dry and the finger seeks the opening in the sac. So flimsy are its walls that it is with difficulty found, but when entered its cavity is explored for secondary cysts. These are ruptured. Removing the gauze pads from the pelvis, the surgeon packs the cul-de-sac opening with iodoform gauze which passes just within the cut edges of the vagina. The uterus is replaced and the vagina packed with gauze. I do not pack the cyst cavity. It closes spontaneously without artificial drainage, there being no pus present.

The first dressing is made in seven to ten days and repeated as often as soiled. After the second dressing the patient is allowed out of bed.

ADHERENT RETROPOSITIONS.

While this book does not treat of all forms of displacement, there is one so commonly associated with inflammation of the adnexa that I may describe my method of dealing with it through the vagina. I shall exclude from this discussion all cases of congenital displacement and

shall deal only with those which have been accompanied or caused by either gonorrheic or septic infection, for I believe the congenital cases are incurable (Fig. 35).

The difference between the free and the adherent retropositions is that the latter are complicated by false bands which bind the displaced uterus to the lower and posterior portions of the pelvis, and also commonly present some degree of tubal disease.

Before any attempt at replacement of an adherent

uterus can be made, the false bands of union must be severed. This can be done in one of two ways: either through the abdomen or through the vagina. If the operation is performed through the belly, the fundus uteri is suspended from the anterior abdominal wall (Kelly's method), or else the anterior surface of the uterus is stitched to the upper wall of the bladder (Pryor, N. Y. Jour. Gynec. and Obstet., July, 1893). Few objections can be made to either operation, except that both necessitate an invasion of the abdominal cavity and conservative treatment of the inflamed adnexa is limited in scope. Of the vaginal methods there are two, one of anterior colpotomy (Dührssen-Machenrodt, etc.), which is condemned because it interferes so often with subsequent pregnancies; and the other, the operation I have for years been performing. I have been struck with the invariable observance of one of two rules in all operations which succeed in keeping a retroposed uterus forward: either this is accomplished by fastening the corpus uteri forward, or else by fixing the cervix high and backward so that the intra-abdominal pressure will force the body of the uterus forward. This latter is the way a pessary acts, and this is the idea embodied in my operation.

Operation. The patient is prepared locally and generally as for a capital operation. I begin the operation with a curettage. The cul-de-sac is then opened (see Exploration). Upon entering the pelvic cavity I make a careful digital exploration. If I find a pus focus. I abandon all further attempts at replacement by the vagina, and treat the case as one of suppuration. But if I find any condition of the adnexa that will not require their removal (see Conservatism), I continue the operation. Occluded tubes are opened and other adhesions are severed. The pelvis is then wiped dry, and a gauze. pad inserted. The patient is tilted into the Trendelenburg posture and the gauze pad is removed. uterus is packed with iodoform gauze. selects a piece of iodoform gauze wide

The The operator enough to fill

119

the vaginal opening and about one and a half inches long. This is inserted just within the edges of the vaginal rent. Over this enough strips are placed to fill the incision in the vagina. This gauze plug, together with the uterus, is next replaced. It is easily done, as the patient is head down and the intestines have left the pelvis. Holding the uterus in position, by means of the trowel or any depressor pushing against the cervix, pieces of gauze are inserted to the sides of the cervix and in front of it until the vagina is filled to the margin of the levator ani muscle. The operator now takes a stout roll of gauze as thick as his thumb and as long as the width of the distended vagina, usually two inches. This I call my gauze pessary. One end of this is introduced in front of one side of the cervix, just behind the levator ani fibers, and the other end is pushed into a similar position on the other side. This plug will lie transversely across the vagina and in front of the cervix. (Fig. 36). It will prevent descent of the cervix even in face of the most violent vomiting. The uterine packing should be so arranged that it can be removed without disturbing this anchoring plug.

A self-retaining catheter is introduced and is emptied every two hours for two days. The bladder is then irrigated with boric acid solution and the catheter withdrawn. The uterine packing is now removed without disturbing the vaginal. In seven to ten days the patient is placed in Sims' position. All dressings are removed and replaced exactly as were the first. The operation will fail unless the supporting plug is properly inserted. This is as important as the suture in other operations. The second dressing is applied a week later, is painless, and after it the patient sits up. I keep up these dressings as long as there is any raw surface at the vaginal vault; the supporting tamponade I use for six weeks. The woman is then allowed intercourse.

If at any time the dressings are so applied that they allow of descent of the uterus, they have been improperly inserted. The cervix must be kept high and backward