cyst may cause death, or the opening may be closed by inflammatory exudation and the cyst refill. It has also been claimed that the cyst may disappear, and the patient recover. When this spontaneous recovery occurs after the bursting of a cyst, there is always room for doubt about its being an ovarian cyst. For the present it must remain an open question whether ovarian cysts ever disappear in this way. It is, however, well known that cysts of the ovary frequently burst and empty their contents into the abdominal cavity. The results of this differ greatly; sometimes there is not much trouble if the fluid is clear and non-irritating; in other cases death is caused in a short time by shock, or peritonitis may follow and cause death or terminate in closing the opening in the cyst and forming extensive adhesions of the cyst- and abdominal-walls and viscera. In those cases which recover from the shock of rupture and the subsequent peritonitis and the cysts refill there are always extensive adhesions found.

Perforation differs from rupture in being a slow process and in the fact that the opening is frequently into the adjoining viscera of the abdomen or pelvis. There are two ways in which perforations occur; the one by thinning of the cyst-wall from pressure, either from within the cyst or from without at a given point, and the other and most frequent by suppuration or ulceration. Perforation occurring in either way may open into the peritonæum, but in case the opening is the result of suppuration it may be into some of the neighboring organs. In some cases the perforation is very small and the opening is closed by exudations which also form adhesions to the neighboring organs. This fact has led to the belief that many of the adhesions found are the result of these small perforations which admit of a limited escape of the cyst fluid. Should the perforation be large a free escape of the fluid may take place, and the result would be the same as in case of rupture. When the perforation is into the intestine, the contents of the sac may be wholly emptied, but this form of perforation is rare.

Another rare form of perforation has been seen in which a communication between an ovarian cyst was formed by ulceration extending from the intestine and opening into the cyst.

Ovarian Cystitis.-Inflammation of the interior of the cyst occurs occasionally and is a serious complication. In multiple and multilocular cysts the inflammation is usually limited to one or more of the cysts, the others in the tumor remaining in their original condition. The inflammation is of a low form in most cases and ends in suppuration; in others there is a mixture of pus with shreds and

flakes of lymph. The original fluid in the cyst is supplanted to a large extent by these products of inflammation.

This was well illustrated in a case of a monocyst which came under my care years ago. I tapped the cyst, and withdrew a half a pint of clear fluid, inflammation followed, and the cyst slowly filled up but did not increase beyond its original size. It became adherent to the abdominal wall and finally opened externally, and it was then found to be filled with pus.

In another case a hypodermic syringe full of clear fluid was drawn off from the major cyst of an ovarian tumor, and then inflammation followed, and the patient was subsequently brought to me for operation. I found pus and lymph in the cyst, but the most of the original clear fluid had disappeared.

Abdominal dropsy is still another complication which may occur. There is in many cases a little free fluid in the peritoneal cavity which is not of special interest, but in other cases the quantity of fluid is such that it may in bulk exceed that of the ovarian tumor. This is more likely to occur in malignant growths and in papillary ovarian cysts. This will be referred to again while discussing diagnosis and treatment.

There are many local and constitutional conditions which may be found accompanying ovarian tumors, but those complications which can be rationally considered as resulting from the affection of the ovary have been mentioned.

CHAPTER XXVII.

CYSTIC TUMORS OF THE OVARIES-SYMPTOMATOLOGY AND PHYSICAL

SIGNS.

THE most peculiar feature in the clinical history of this variety of ovarian tumor is the fact that subjective symptoms are often absent. Cases are sometimes seen in which the patient is unconscious of anything being wrong until the tumor becomes noticeable by the increased size of the abdomen. It is equally strange that the tumor is often unobserved by the patient until it has attained a considerable size. But, while cases occur without noticeable symptoms, the majority of patients suffer from some pain and discomfort, and at the same time there is more or less derangement of the function of the ovaries, and occasionally some disturbance of neighboring organs. The symptoms differ in the different stages of the growth of the tumor. I will, therefore, take up the three stages in order. In the first stage, while the tumor still occupies the pelvic cavity, the patient may have a feeling of fullness in the pelvis, and possibly some pelvic tenesmus on standing or walking; pain is also present in the affected side. The severity of the pain differs greatly in different cases. In some it is only sufficient to attract the attention of the patient at times, but is not acute enough to prevent her from performing her ordinary duties. In others it is quite severe, and accompanied with well-defined tenderness, disabling the patient to some extent. These symptoms may or may not be continuous. The pain may be at times very slight for days or weeks, then increase, and again subside, and yet at no time be sufficiently marked to cause the sufferer to seek advice, and its existence is only brought out by interrogation at a more advanced stage of the affection. When the pain is acute and sufficient to disable the patient, there is usually some local inflammation to account for it. When such is the case, there is ordinarily some constitutional disturbance indicative of the local affection. In quite a number of

cases there is pain for a few days at or just before the menstrual period, or it may be midway between the periods.

The pain is in the affected ovary, and is often of that character which is called ovarian. It has been supposed that this kind of intermittent pain is due to ovulation, occurring in the morbid ovary. When the pain occurs in the intra-menstrual period, it is presumed to be caused by some trouble during the maturation of the ovule; and, when it comes on about the menstrual period, it is due to the process of rupture of the Graafian vesicle. Menstruation is frequently deranged, but not always. While one ovary is affected, the other may be normal, and, so far as the ovaries influence menstruation, there is no change, and the uterine function goes on in the usual way. This is sometimes the case when both ovaries are affected. It would appear that, while a part of the ovaries is morbid, there still remains enough that is normal to perform the func tion and maintain the ovarian influence upon menstruation. It frequently happens, however, that menstruation is deranged during the existence of ovarian tumors. As already stated, there may be pain at the menstrual period, which is easily mistaken for dysmenorrhoea. Irregularity or suppression of the menses is, I believe, the most common derangement. Profuse and too frequent menstruation occasionally occurs, but either of these derangements may be due to some constitutional condition or some uterine affection, which may accompany the ovarian tumor. When the ovarian tumor attains considerable size, and is yet not large enough to rise out of the pelvis, it may cause displacement of the uterus or bladder, and give rise to symptoms peculiar to this displacement. It is not often that these cause sufficient suffering to lead the patient to seek relief at the hands of the gynecologist. When the left ovary is the subject of the morbid growth, there is, in some cases, slight obstruction of the rectum, which causes disturbance in the action of the bowels.

The important fact still remains that, in the first stage of cystic tumors of the ovaries that are uncomplicated, the symptoms are often so mild that the patient may not come under the care of the medical attendant, and, if she does, the symptoms do not afford any reliable guide to the nature of the affection.

In short, there is nothing diagnostic in the symptomatology of this stage of ovarian tumors.

In the second stage, an enlargement of the abdomen is noticed sooner or later by the patient. If the pedicle is short, the enlargement may be on one side; usually it is central, or nearly so, when first noticed. Here, again, there are no other very well-marked

symptoms. As the tumor increases, the weight and pressure cause discomfort. This is likely to be felt earlier in those who have not borne children than in those who have. In such patients the abdominal muscles do not yield so readily to accommodate the tumor. Slight pains recurring at intervals and tenderness are common symptoms, and are usually due to tension of the cystic walls from increase of the contents. When such pains occur, the tension of the cyst is marked, and the pain subsides when the cyst becomes flaccid. If inflammation of the cyst or portions of the peritonæum occurs, there are, in addition to pain and tenderness, some constitutional symptoms, such as fever, rigors, and, if the inflammation is extensive, deranged digestion, loss of flesh, and hectic may follow. These symptoms are relied upon as indicating inflammation, which will produce adhesions, especially if the peritoneum is involved; but it should be borne in mind that quite extensive adhesions may take place without their having been at any time well-defined symptoms of circumscribed peritonitis. Ordinarily, these are all the symptoms manifested in the second stage.

In the third stage, when the tumor begins to make strong pressure upon the different viscera, another class of symptoms appears. These were hinted at while discussing the growth of ovarian tumors. Deranged digestion and impaired micturition, difficult breathing, distressing weight, and a dragging on the abdominal muscles, together with pain and tenderness, may all supervene. Some of the symptoms which characterize the first stage, and disappear in the second, often recur in the third. Pressure on the bladder may cause frequent urination, and the bowels may become obstinately constipated. Paroxysms of pain in the limbs and abdomen may be very severe, caused by obstructed circulation. From the same cause effusion of fluid into the abdominal cavity and oedema of the legs may

occur.

The patient becomes emaciated, weak, and sometimes hectic, but not, as a rule, cachectic in the benign forms of ovarian tumors.

Physical Signs.-The physical examination of ovarian tumors is made by the means generally employed, and fully described in the first chapter of this work. They are inspection, vaginal touch, palpation, percussion, auscultation, measurement, exploration by aspiration, microscopical and chemical examination of fluid obtained by aspiration, and, finally, laparotomy. The evidence obtained by physical exploration differs in each stage of the growth of ovarian tumors. In the first stage, the bimanual examination of the pelvic contents is all that is necessary, this giving all the information which can be