tion, and is increased by standing erect. By bimanual examination with one finger in the rectum a distinct doughy tumor or knotted swollen vessels may be felt in the broad ligament.

Prognosis. Some patients suffer so much that they are unable to stand or walk, and are bedridden invalids for years. The dilated veins may rupture, and form a hematocele or hematoma (see below). Diagnosis.-Salpingitis causes a sausage-shaped tumor; oöphoritis is harder and more painful; cellulitis and pelvic peritonitis have more diffuse contours, and none of them becomes smaller in the recumbent position. A swollen vein may be confounded with a swollen ureter, but in the latter condition other symptoms of a pathological state of the uropoietic organs are present.

Treatment. If the condition is recent, hot douches, tincture of iodine, ichthyol glycerin, or faradic electricity, combined with frequent rest in a recumbent position and attention to the bowels, may effect a cure. If it is old enough to have produced permanent dilatation of the veins and thickening of their walls, nothing is likely to be of avail except an extirpation of the affected part of the broad ligament, together with the tube and ovary; which may be done by tying it with the cobbler's stitch or some other form of a chain-ligature, and cutting the parts away above the ligature.1

B. Cysts of the Broad Ligament.

Not every cyst situated in the broad ligament is a cyst of the broad ligament. We have seen above (p. 585) that ovarian tumors may develop downward into the broad ligament and even far beyond its base. A Graafian follicle or a corpus luteum may form such a cyst. By a cyst of the broad ligament is meant a cyst developed in the broad ligament outside of the ovary. Such cysts are sometimes called parovarian cysts, but this name is not quite correct, for the parovarium is a definite organ found in a definite locality, and, if it is true that such cysts may develop in it, it is no less true that they may develop in any other part of the broad ligament. The schematic figure 330 gives a good idea of the locality of such cysts.

Cysts of the broad ligament are much rarer than ovarian cysts. As a rule, they are monocystic, but exceptionally polycystic tumors of this origin have been found. Commonly, they do not exceed the size of a pregnant uterus at six months' gestation, but exceptionally they may become enormous.

1 The disease has been described, with report of four cases in which laparotomy was performed successfully, by A. P. Dudley of New York in the N. Y. Med. Jour., Aug. 11 and 18, 1888-a paper that has been severely, and in my opinion rather unjustly, criticised by Coe in Amer. Jour. Obst., May, 1889, vol. xxii. p. 504. I have myself operated on a case of this kind-Mrs. H., St. Mark's Hospital, Feb. 19, 1894. The left broad ligament formed a conglomeration of tortuous dark blue, almost black veins, each as thick as a lead pencil, situated between the uterus and the tube.

As a rule, the wall is so thin as to be translucent or transparent, but in exceptional cases the cyst may look like a uterine growth on account of a thick layer of smooth muscle-fibers. The wall is composed of the peritoneum with its endothelium; a layer of connective tissue containing some plain muscle-fibers; often glands, which do not open into the interior; and very few blood-vessels, which gives it a

Diagram of the Structures in and adjacent to the Broad Ligament (Doran): 1, framework of the parenchyma of the ovary, seat of 1 a, simple or glandular multilocular cyst; 2, tissue of hilum with 3, papillary cyst1; 4, broad-ligament cyst independent of parovarium and Fallopian tube: 5, similar cyst in broad ligament, above the tube, but not connected with it; 6, similar cyst developed close to 7, ovarian fimbria of tube; 8, the hydatid of Morgagni; 9, cyst developed from horizontal tube of parovarium; 10, the parovarium: the dotted lines represent the inner portion, always more or less obsolete in the adult; 11, small cyst developed from a vertical tube: 12, Gartner's duct; 13, track of the same in the uterine wall.

white color. Its interior surface is smooth or wrinkled, but has no glandular formations, and is covered with a single layer of vibratile, low columnar or flat epithelium. As a rule, these cysts extend right up to the tube, that becomes imbedded in the wall without mesosalpinx. Like ovarian tumors, they may develop below the broad ligament, and come to lie below, in front of, or behind the peritoneum. They may become so large as to be much more abdominal than pelvic

tumors.

The fluid is normally watery, nearly colorless, and alkaline or neutral. It does not coagulate spontaneously, nor to any extent by heat before adding an acid. It contains a few cells and Bennett's large and small corpuscles (Figs. 301, 302, and 308, pp. 577, 578). But in exceptional cases a thick colloid fluid has been found in such cysts. Papillary and dermoid cysts may also develop in the broad ligament. As a rule, cysts of the broad ligament are sessile, but sometimes This theory about the origin of the two kinds of ovarian cysts is not generally admitted.

the ligament forms a pedicle, which may even become twisted, an accident that may lead to gangrene of the tumor.

These tumors are found in the period of sexual maturity. They grow very slowly. They do not impair the general health, and give rise to no symptoms except by their bulk.

Diagnosis.-A small cyst of the broad ligament may be felt in the pelvis separate from the ovary and tilting the uterus over to the opposite side. It may be so like hematoma that it cannot be distinguished from it except by the history, the latter developing rapidly, and being reabsorbed after some time. The distinction from ovarian, especially intraligamentous, and other abdominal cysts may be very difficult. The leading points are the slow development, slight pain, absence of cachexia, the low seat, absence of solid masses, a very distinct fluctuation-wave, flatness in front, and greater fullness in the flanks.

It is impossible to tell for sure, by the fluid alone, whether a tumor is ovarian or a cyst of the broad ligament, although the presumption may be strongly in favor of one or the other2: both ovarian cysts and cysts of the broad ligament may have serous or colloid contents, but the latter is common in ovarian cysts, rare in extra-ovarian, while the watery is common in extra-ovarian, rare in ovarian cysts. Still, it may be found, not only in true monocysts, but in multilocular cystomas of the ovary.

Treatment.-Small tumors of this kind should be let alone. When by their bulk they become troublesome, the best thing to do is to remove them exactly like an ovarian tumor. Sometimes there is a pedicle, and sometimes one can be made of the peritoneal covering during the operation. Enucleation is, as a rule, easy. If it meets with difficulties, the sac should be cut open and the left hand introduced to help the right hand separate the cyst from the peritoneum. After the enucleation the empty shell may be tied as a pedicle in one or more sections, or the edges may be stitched together with catgut, or they may be brought together as a purse and fastened to the abdominal wound. The cavity is packed with iodoform gauze, and will fill by granulation, but, as a rule, only with suppuration. If the tumor cannot be enucleated, the whole sac may be fastened to the abdominal wound (marsupialization). Redundant tissue is, of course, cut away in all these procedures.

Another way of operating is simply to cut out a large circular piece of the wall and close the abdomen.

These cysts used to be treaty tapping or aspiration, and their

ing one that had been tapped five years ot become larger than the uterus at the

innocuous nature and the slowness to refill of most of them are indeed great inducements to use that kind of treatment; but since it has been discovered that some of them are papillomatous, and the radical operation in most cases easy and safe, extirpation is preferred by most gynecologists.

If the ovary and tube are healthy and placed so that they need not be removed, they should be left behind.

C. Solid Tumors of the Broad Ligament.

Besides uterine fibroids which grow in between the layers of the broad ligament, and of which enough has been said in speaking of that disease, the broad ligament is occasionally the seat of solid tumors which take their origin in the ligaments themselves. Thus, myomas, fibromas-sometimes melting to fibrocysts-lipomas, and sarcomas, have been observed. Such tumors may push the vagina before them and protrude into the vulva, or grow out through the greater sciatic foramen, simulating a hernia.

All solid tumors of the broad ligament should be removed by laparotomy as soon as discovered.

CHAPTER IV.

DISEASES OF THE ROUND LIGAMENT.

IN an earlier part of this work (p. 256) we have said that any part of the round ligament may become the seat of a fibroma, and that this occurs more frequently outside than inside of the pelvis. The fibrous tissue is commonly blended with muscular, myxomatous, or sarcomatous tissue, constituting a myofibroma, myxofibroma, or fibrosarcoma. In one case the lymphatics were much distended (fibroma lymphangiectodes).

The affection is much more common on the right side than on the left. The diagnosis may be very difficult. The treatment consists in early extirpation.

CHAPTER V.

DISEASES OF THE SACRO-UTERINE LIGAMENT.

WE have seen above (p. 426) that inflammation of the sacro-uterine ligament is a chief cause of anteflexion of the uterus. One or both ligaments are swollen, tender on pressure, and become shortened through cicatricial contraction.

The usual antiphlogistic treatment, especially ichthyol glycerin, tincture of iodine, hot douche, and the galvanic current, is indicated, and often yields good results in fresh cases; and even a chronic shortening may be overcome by means of vaginal packing (p. 178).

Since these ligaments form the chief support of the uterus (p. 55), their loss of tonus and elongation, usually due to childbirth, are principal factors in the production of prolapse of the uterus (p. 454). The loss of tonicity may perhaps be remedied by the use of the faradic current or massage. If not, recourse must be had to pessaries, supporters, or the operations indicated for prolapse (p. 457).

P. S. BRUGUIERE, M. D.

CHAPTER VI.

PELVIC HEMORRHAGE.

INTERNAL hemorrhage from the genitals and the parts near them takes place in three ways, differing widely from one another as to frequency, anatomy, danger, and treatment, and which it is, therefore, appropriate to designate by three different names and to describe apart from one another. Since, however, most authors follow a different course in this respect, it is necessary to add the other names under which the described conditions are known.

The blood may be poured freely into the peritoneal cavity. We call this simply intraperitoneal hemorrhage, but most writers class it with the second condition, and call it non-encysted hematocele or cataclysmic hematocele. Secondly, the blood may enter the peritoneal cavity, and become limited by inflammatory exudation, so as to form a tumor. We call this hematocele, but it has been designated as pelvic hematocele, intraperitoneal hematocele, or true hematocele. (always comprising the free intraperitoneal hemorrhage). Finally, the extravasated blood may be situated in the connective tissue of the broad ligaments, the pelvis, and the abdomen. This condition we designate as hematoma, but it is also called extraperitoneal hematocele, false hematocele, pseudohematocele, or thrombus. (Compare Thrombus of the Vulva, p. 276.)1

A. Intraperitoneal Hemorrhage.

If a large amount of blood is poured rapidly into the healthy peritoneal cavity, it meets with no resistance, the intestines are pushed aside, and the abdominal wall becomes distended.

Etiology.-Most cases of abdominal hemorrhage are traumatic and

1 Rosenwasser of Cleveland, Ohio, unites the two last condition, under the name of circumscribed or limited, hemorrhage, opposed to the first, which he calls free hemorrhage (Trans. Amer. Obstetricians and Gynecologists, 1893).