Ovariotomy with Complications.—While few operations are simpler than an uncomplicated ovariotomy, there is probably no abdominal operation which demands more skill and resource than the removal of a cyst with dense and short adhesions, especially when on the posterior and pelvic aspects of the tumour. Adhesions to the anterior abdominal wall, the omentum and the transverse colon may be dealt with by wiping them off the tumour surface with a gauze sponge if soft and filamentous or by ligaturing and dividing if tough and stringy. When the bowel is closely and firmly adherent to the cyst a careful dissection should be made, the outer fibrous layer of the cyst wall being peeled off it and left adherent to the bowel. If the tumour is densely adherent to the pelvis it may be impossible to remove it, and the adherent outer fibrous layer of the wall may be left behind, the epithelial lining being dissected off or destroyed by the cautery; drainage must be provided in such a case. Communica tions with the bowel or bladder, if present, demand the suturing of the viscus, which may also be called for in the event of a tear resulting from the incautious use of force in separating adhesions.
Ovarian Cysts in Pregnancy and Labour.—When a patient with ovarian cyst becomes pregnant, or when a pregnant woman is found to have an ovarian cyst, the proper treatment will depend upon circumstances. The risks of such a condition are, first, that the tumour will interfere with delivery by becoming impacted in the pelvis; and, secondly, that torsion of the pediele of the tumour will occur in all probability either before the labour or shortly after it. If torsion has occurred, if the tumour has been discovered before the middle of pregnancy, or is of such a size that it and the enlarging uterus arc likely to cause dangerous pressure symptoms, it is wise to remove it, as recovery is usually good and the pregnancy often continues without interruption. On the other hand, if the tumour is not
discovered until the latter half of pregnancy, and if it is not causing symptoms, I should wait and sec. If it obstructs labour, Cwsarean section and ovariotomy should be done at an early stage; if torsion occurs, ovariotomv may he done at once; if labour passes off without incident, ovariotomv can be done in the later weeks of the puerperium.
Follicular and Lotein Cysts of the Ovary.--illany cases of what may be called clinically " ovarian trouble •' are due to the presence of cysts originating in distension of a Graafian follicle or lutein body. These cysts may be single and attain a considerable size. They are more usually multiple, forming what is known as a " small cystic ovary." Pain is a prominent symptom, a point of distinction from true ovarian tumours, which only cause pain through pressure or when complicated by inflam mation or torsion. The pain is sometimes relieved by treatment on the lines laid down for chronic inflammation of the ovaries (q.v.), but in most cases resection ultimately becomes necessary. The ovary is delivered through a 3 to 4 inch abdominal incision, or through the anterior fornix of the vagina, according to the preference of the operator, and a wedge running in the long axis of the ovary is excised. This portion should as far as possible contain all the cysts, and if any are cut through the portions left in the stump should have their epithelial lining removed by wiping with a gauze swab. The gap in the ovary is then united by a continuous catgut suture and the ovary dropped back into the abdomen. Large solitary follicular or lutein cysts may be treated as an ovarian cyst and the whole ovary removed.—R. J. J.