Some practitioners, again, have declared themselves in favor of tapping the ovarian cyst, rather than inducing premature labor, thus anticipating the dangers of rupture or gangrene of the cyst without sacrificing the child. And then comes the triple question, in reference to ovariotomy, whether it should be performed at all during the existence of pregnancy; whether, if done it should be supplemented by the Cæsarean section; and, thirdly, whether if, during ovariotomy, the uterus should give away or be accidentally opened, its contents should be cleared out, or the parts left to themselves?"

After a careful consideration of a number of cases Wells arrives. at the following conclusions:

"1. Pregnancy and ovarian disease may go on together, and may end in the birth of a living child and the safety of the mother.

"2. But in a large proportion of cases, probably in nearly all where an ovarian tumor is large, there is danger of abortion; or, if the pregnancy proceed to the full term, of lingering labor and a still-born child; and throughout the latter months of pregnancy there is danger of sudden death to the mother from rupture of the cyst or rotation of its pedicle.

"3. Spontaneous premature labor may not save the mother from these perils, and the induction of premature labor artificially almost implies sacrifice of the child with considerable risk to the mother.

"4. There is no proof that tapping an ovarian cyst is more dangerous during pregnancy than at any other time; and if there be a large single cyst, tapping will afford immediate relief to distension at a very slight risk to the mother, and lead to the natural termination of pregnancy in the birth of a living child, if proper precautions be taken to prevent the escape of ovarian fluid into the peritoneal cavity, and the entrance of air into this cavity, and into the cavity of the cyst. In cases of multilocular cyst tapping can be of very little use.

"5. In cases of multilocular cyst, or solid tumor, the rule should be to remove the tumor in an early period of pregnancy: and if an ovarian cyst should burst during pregnancy at any period, removal of the cyst and complete cleansing of the peritoneal cavity may save the life of the mother, and pregnancy may go on to the full term.

"6. Of three cases on record where a pregnant uterus has been punctured during ovariotomy, the recovery was in the one case where the uterus was emptied before the completion of the operation."

In Barnes' Lectures on Obstetric Operations, page 305, the author states the following conclusions, rising from the simplest cases to those of extremest difficulty:

"A.-In the case of tumors complicating pregnancy:

"1. Induce premature labor.

"2. If the tumor be ovarian fluid, and distress great, tap it. "3. If ovarian tumor burst or become strangulated during pregnancy, remove it by gastrotomy.

"B.-In the case of tumors obstructing labor, that is, presenting before the child:

"1. Push the tumor aside, if possible.

"2. If the tumour be fluid, lessen its bulk by puncture.

"3. If solid, puncture by aspirator-trocar, and if still not diminished in bulk, remove it altogether by enucleation or by wire.

"4. If the tumor can not be advantageously acted upon, reduce the bulk of the child. Turn, perforate, crush the head by cephalotribe, break up the cranial vault, remove it by sections by wire écrasuer.

"5. If neither tumor nor child can be advantageously acted upon, have recourse to the Cæsarean section.

"C. When the tumors present after the birth of child:

"1. If polypoid, remove early after labor by wire écraseur or galvanic cautery wire.

"2. If sessile or projecting in a marked degree from the inner surface of the uterus, more especially if seated in the cervix, or lower zone of the uterus, so that they have been bruised by the passage of the child, remove if possible by enucleation.

"3. If they can not be so removed, try to promote expulsion by quinine, by subcutaneous injection of ergotine, and watch to counteract septicemia."

Emmet, in his work on "Principles and Practice of Gynecology," page 708, Ed. 18—, says:

"As a general rule an ovarian tumor should not be removed if early pregnancy co-exists, from the fact that in a certain proportion of cases miscarriage will occur and the patient die. But it would be equally wrong to permit a woman to go to full term without relief, if she were likely in consequence of the size of the tumor to suffer from the effects of the additional pressure, whereby the death of both mother and child may be brought about. We have always to recognize the danger of additional adhesions forming in some

unusual manner or place, as a consequence of the displacement of the tumor by the enlarging uterus. These may be of such a character as to render the removal of the tumor afterwards impossible, as was the case with the patient in whom the stomach and colon became adherent to the tumor. Moreover, the lives of both may be lost if this undue degree of distention is permitted to continue,. when indications exist of functional derangement of the kidneys, or of impaired nutrition elsewhere. The danger of rupture of the tumor, and the consequences to both mother and child, must always be considered in advanced pregnancy, and finally the evil effect of a tedious labor upon the child, even if the mother should escape, should be remembered. If the tumor is unilocular, tapping should be resorted to for temporary relief. But should it be multilocular, and the case as described above be an urgent one, the tumor should be removed without delay, in the interest of the mother. Fortunately, when the operation is done before uræmic symptoms have become marked, the recovery of the mother will not necessarily be complicated by the existing pregnancy, and the probabilities will be good for the future progress of the gestation to a favorable end.

"Dr. Sims removed, in 1860, a very large unilocular cyst, with-out adhesions, from a private patient, between the third and fourth months of pregnancy. I had charge of her after the operation; the pulse never rose above ninety a minute; she recovered without a bad symptom, and had three children afterwards.

"Dr. W. L. Atlee also operated on a patient under the same circumstances, and without any bad consequences."

In his "Private and Practical Gynecology," p. 709, Emmet states that Dr. Playfair had collated fifty-seven cases of this complication, in thirteen of which the mothers were lost; in seven cases where the cyst was punctured, they all did well, and gestation was not interrupted. Dr. Braxton Hicks cites eight instances of ovarian tumors complicated with pregnancy, in which the women went to full term, and were delivered of living children.

Lawson Tait, in his work on "Diseases of the Ovaries," page 293, says:

"Occasionally we are called upon to deal with an ovarian tumor in a woman who is pregnant-a complication which may or may not be discovered before the operation. Some years ago the ques-tion of the propriety of removing an ovarian tumor in a pregnant woman was discussed before one of the medical societies, and various opinions were given. By some obstetric physicians the

Before The result was

opinion was expressed that it would be better to induce premature labor, and that after the patient had recovered from this, we should perform ovariotomy. Mr. Spencer Wells and myself, on the other hand, contended that it would be much better to perform ovariotomy and leave the pregnancy alone, and this plan has now become the accepted practice. At that time Mr. Wells had operated upon ten pregnant women, and nine of these cases were successful. I do not know what his experience may have been since, and I have not found any record of the experience of any one else upon this subject; but since the discussion I have operated upon ten pregnant women with uniform success. that time I had only operated in one such case. fatal, and was undoubtedly due to the use of the clamps, for the cause of death was gangrene of the pedicle. I do not now think pregnancy offers any bar to the operation. In all my cases I have been able to recognize the pregnancy before I opened the abdomen but I can easily imagine that it might occur to the most experienced surgeon to operate on a woman in whom he had not previously recognized the existence of the complication. Indeed, Mr. Wells tells us of a case in which he punctured a pregnant uterus with a trocar, having mistaken it for a cyst. He opened the uterus, emptied it of its contents, and the patient recovered.

;

NOTE. "(A similar accident happened to Dr. Byford, of Chicago, and he successfully followed out the same practice as did Mr. Wells. Am. Jour. of Obstetrics, Jan. 1879.).

"This is one of the complications, therefore, to be especially borne in mind. The usual color and appearance of an ovarian cyst is as a rule sufficiently characteristic to make it easily recognizable from a pregnant uterus; yet I can easily imagine circumstances such as Mr. Wells encountered, that would lead to such a mistake; and should this misfortune happen, the bold proceeding he followed would certainly be the best practice."

Lusk, in his work, "The Science and Art of Midwifery,” p. 512: "Ovarian tumors are a dangerous complication of pregnancy. Playfair reports fifty-seven cases, with thirteen deaths. The treatment, when the tumor interferes with delivery, consists in reposition, or, failing, after persevering effort, in puncture of the cyst. The cul-de-sac of the vagina affords generally the most convenient point for introducing the trocar. The time selected for tapping should be during the existence of a pain, when the cyst is rendered tense by pressure.

"Owing to the rapid increase in the size of the tumor which commonly results from pregnancy, and in consideration of the relatively favorable issue of ovaritomoy performed upon pregnant

women, the radical operation during pregnancy may possibly prove in the future the most advantageous form of treatment."

"Science and Art of Obstetrics," Parvin, page 272, concerning ovarian tumors, the author says:

"If an ovarian tumor be small, it presents no serious interference, if any, with pregnancy. But if the tumor be large the pregnancy in many cases ends in abortion, or in premature labor. Other accidents are inflammatory adhesions between the tumor and the fundus of the uterus, rupture of the cyst wall, twisting of the pedicle of the tumor, and consequent gangrene. In some cases where the tumor is not large, it may become wedged in the pelvic cavity. The treatment of ovarian tumors, so long as they do not give the patient discomfort and threaten the pregnancy, is expectant. But when the tumor is fixed in the true pelvis, an effort should be made, with the patient occupying the knee-chest position, to push it up out of the pelvis.

"Large tumors are to be treated by abortion, tapping, or ovariotomy. The first is generally rejected, and the second is only applicable to a monocyst, or to a tumor which is composed chiefly of one cyst. The general professional sentiment is in favor of ovariotomy if the tumor be large; the results are usually good, and especially if the operation be done early in the pregnancy.

"The following facts and conclusions are found in a recent valuable monograph by Remy:

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"In eleven cases of pregnancy complicated with ovarian tumor occupying the abdominal cavity in which premature labor was induced, three mothers died, and of the eleven children only five lived. Puncture of the cyst, according to Heiberg's statistics, has a maternal mortality of 22.5 per cent., and a foetal mortality of 37.5 per cent.'

"Ovariatomy in pregnacy was first suggested by Merriman in 1817, and was first successfully done by Marion Sims; the operator, however, did not know before the operation was begun that the patient was pregnant.

"The mortality for mothers from ovariatomy in pregnancy is, when the operation is done in the first four months, 11.3 per cent., and for the foetus 42.8; if the operation be done in the last five months the maternal mortality is 16.6 per cent., and the fœtal mortality 50 per cent. Expectation-of course it is presumed that the ovarian tumor is of considerable size-gives a maternal mortality of 39.2 per cent. and a foetal mortality of 67 per cent.

"Schroeder has recently done his fifteenth ovariotomy in pregnancy, the recovery of the patient without interruption of the