In

eral years before a second tapping became necessary. still fewer cases the tapping seemed to be curative, the tumor never reappearing after it had been evacuated. Such cases were so unusual that they should have no influence whatever in determining the method of treatment. In the great majority of instances the cyst rapidly refilled. Sometimes the fluid accumulated with such rapidity that evacuation became necessary every few days. Referring again to the old records, we find a case which was tapped 664 times in thirteen years-once in about seven days!

If the cyst were multilocular, tapping furnished but partial relief.

The proceeding itself was attended by serious dangers. Dr. Fock of Berlin in 1856 stated that 25 out of 132 women or 1 in 51⁄2-died within some hours or a few days after the first tapping. Another operator lost 9 out of 64 cases-or very nearly 1 in 7-within twenty-four hours after the first tapping. The chief mortality occurred in the cases of multilocular tumors. Tapping the unilocular tumors was attended by much less danger.

The sources of danger from tapping were the following: hemorrhage from puncture of a vessel in the cyst-wall; septic or other infection of the peritoneum; and inflammation or suppuration of the cyst.

The majority of the women died in consequence of peritoneal infection.

The danger arose not only from septic infection of the peritoneum, but from papillomatous or other infection from the escape into the peritoneal cavity of some of the cyst-contents. Reference has already been made to the occurrence of the papillomatous infection at the site of puncture in the abdominal wall.

At the present day tapping an ovarian cyst with the hope of cure is never practised.

Tapping as a palliative procedure should never be performed. The dangers that may result from the tapping cannot be disregarded, and no hope whatever of cure can

be held out to the patient. When operation is finally performed, it is rendered much more difficult from the adhesions that have resulted from previous tappings.

Operation. The treatment of ovarian cysts is operative. Celiotomy should be performed and the tumor removed without delay. The dangers due to the accidents. that may occur show the risk of waiting after a diagnosis has been made. When the tumor is small the operative complications and dangers are at a minimum.

Even if the tumor be discovered accidentally by the physician, and has never given any trouble to the woman, operation for its removal should be advised. A dermoid that has existed for years may suddenly endanger the woman's life. Delay in the case of papillomatous tumors and no one can determine in the early stages whether or not a cyst be papillomatous-is especially dangerous. About one-half the women upon whom I have operated for papillomatous cysts have come to me after the peritoneum had become infected. Though the peritoneum be extensively involved, operation is by no means hopeless. As in the case of tuberculosis of the peritoneum, so in papilloma, the opening and draining of the abdominal cavity may result in cure.

Pregnancy is no contraindication to operation. In fact, the dangers of obstructed labor, of rupture of the cyst, and of torsion of the pedicle urgently call for immediate operation in such cases. Pregnancy usually progresses to full term after operation.

CHAPTER XXXII.

SOLID TUMORS OF THE OVARY.

SOLID tumors of the ovary are of rare occurrence. They are said to be found in about 5 per cent. of all the cases of ovarian tumors that are submitted to operation.

The solid tumors of the ovary are fibromata, myomata, sarcomata, carcinomata, and papillomata.

Fibromata. Ovarian fibromata are very rare; they are histologically similar to fibroid tumors of other parts of the body. They do not form circumscribed new growths, but affect the whole organ, which becomes uniformly hypertrophied, preserving its general shape and anatomical relations. The tumor may contain, between the bundles of fibrous tissue, small cavities filled with fluid. The growth is usually intra-peritoneal and has a well-formed pedicle; it may, however, in exceptional cases be extraperitoneal and develop between the layers of the broad ligament. In such a case there is difficulty in determining whether the fibroid originated in the uterus or in the ovary. Ovarian fibromata are usually of small size and slow growth. A case has been reported in which the tumor weighed over 7 pounds.

Corpora Fibrosa.-A variety of the ovarian fibromata are the corpora fibrosa, which are due to fibroid degeneration of the corpus luteum. They are tough, fibrous bodies, about the size of a pea, which are occasionally found upon the surface of the ovary. It is said that they may attain the size of a child's head. They are usually, however, very small, and have no clinical significance.

Myomata. Ovarian myomata are composed chiefly of unstriped muscular fiber. They are somewhat more frequent than the pure fibromata. The two growths may

The my

be mixed, forming a fibro-myomatous tumor. omatous tumor may attain the weight of fifteen pounds. Sarcomata. The majority of solid tumors of the ovary are sarcomatous in character, and it seems probable that many tumors that are classed as fibroids or fibro-myomata are in reality ovarian sarcomata. The growth may be either of the spindle-cell or the roundcell variety.

Sarcoma of the ovary differs from sarcoma in other parts of the body in the fact that it is very often bilateral. Sutton states that both ovaries are affected in about 20 per cent. of the cases. Other observers state that ovarian sarcomata are usually bilateral.

The surface of the tumor is smooth, and the general form and anatomical relations of the ovary are unaltered. Ovarian sarcomata are usually of median size, though they may attain enormous proportions and fill the abdominal cavity.

The tumor is usually of rapid growth; in one case it attained a weight of ten pounds within a period of six months. The growth is accelerated by pregnancy. Ascites is commonly present with ovarian sarcoma, and cachexia may appear rapidly.

Ascites caused by peritoneal irritation may accompany any of the solid tumors of the ovary, as other kinds of freely movable abdominal tumor. It is, however, especially characteristic of the ovarian sarcomata, and is a point of diagnostic importance.

Ovarian sarcomata differ from the fibroid and the myomatous tumors in rapidity of growth, involvement of both ovaries, and the presence of ascites. Ovarian sarcomata may occur at any age. They are relatively very frequent in children. An analysis of 60 cases of ovarian tumors in children collected by Sutton shows that sarcomata occurred 16 times.

The symptoms caused by ovarian fibromata, myoinata, and sarcomata are those referable to pressure and peritoneal irritation. These tumors, on account of their

moderate size and great mobility, seem to be especially liable to torsion of the pedicle. They should be removed by celiotomy as soon as recognized.

Both ovaries should always be carefully examined, for in sarcoma the disease is often bilateral.

Carcinomata.-Primary cancer of the ovaries is very Secondary infection of these organs is, however, It is found in cases of

rare.

of not infrequent occurrence. cancer of the breast and of the uterus. In 29 cases of death from cancer of the breast, both ovaries were found to be involved in 3 cases.

The site of the ovary is occupied by an irregular nodular mass. Ascites is commonly present in cancer of the ovaries, the fluid being often tinged with blood. The disease is of very rapid progress.

When cancer of the ovaries is secondary to cancer elsewhere than in the uterus, operation offers no prospect of cure. If the disease is secondary to cancer of the uterus, it may be possible to remove all of the affected structures. Ovarian Papillomata.-Superficial papillomata of the ovary are of very rare occurrence. In many of the cases in which the papillomata appear to grow from the surface of the ovary there had previously been a papillomatous cyst of paroöphoritic origin, which had become perforated and perhaps inverted, so that, after the cyst had become destroyed, the growths appeared to spring from the ovarian surface. Careful dissection and search for the remains of the old cyst should always be made in such

cases.

In superficial papilloma of the ovary the growths are in all respects similar to those found in the interior of papillomatous cysts. They may be isolated upon the surface of the ovary, or they may cover it so completely that the ovary is hidden from view. A section, however, will reveal the ovary lying in the centre of the growth.

The papillomata may be pedunculated or sessile. They vary in size. In some cases they form a mass larger than the adult fist.