which, on pressure, could be flattened out and made to disappear. The skin around the umbilicus was thin, and of a brown color from deposit of pigment. On palpation and percussion the abdomen was found to be almost entirely occupied by a large tumor, which appeared to be everywhere solid. Its upper margin could be felt about midway between the umbilicus and the ensiform cartilage. It extended entirely across the abdomen, and was lost below in the pelvic cavity.

The intestines were found crowded up towards the liver, the latter organ being displaced upwards. A small amount of fluid could be detected in the peritoneal cavity. On examining per vaginam, the whole roof of the pelvis was felt to be hard and unyielding, as it is usually found in cases of chronic pelvic peritonitis. The cervix uteri was drawn upwards and almost lost in the mass above.

In forming a diagnosis, I was led to regard the tumor as malignant, from its history, and to select the ovary as the seat of the disease chiefly by exclusion. But, inasmuch as solid tumors of the ovary are rare, and solid tumors of this size almost unknown, I had the woman admitted to the Strangers' Hospital, where she could be seen by Drs. E. R. Peaslee and T. G. Thomas in consultation.

After a careful examination of the patient, both of these gentlemen were inclined to concur in the diagnosis already made, although neither of them had ever seen a solid tumor of the ovary of a size at all approximat ing to this. In view, therefore, of the uncertainty of the case, it was agreed in this consultation to make a

small incision through the thin skin of the pouting umbilicus, and see if anything further could be ascertained as to the character of the growth. The patient was accordingly anæsthetized, and an incision about two inches in length was made by Dr. Thomas through the umbilicus.

As seen and felt through this incision, the tumor was everywhere smooth and solid. It was not deemed expedient to make an incision long enough to trace the tumor to its origin or to explore the pelvis. On recov ering from the anaesthetic, the patient was taken with vomiting, which persisted with only short intervals for forty-eight hours, when she died from exhaustion. At the autopsy, which I was obliged to make hurriedly the abdomen only was examined. Its cavity was found almost entirely occupied by a large tumor, which was found to spring from the left ovary. There was a small amount of fluid in the peritoneal cavity, which was estimated at about two quarts.

A few adhesions were found indicating the existence of an old peritonitis.

The right ovary was also diseased and enlarged to about the size of a turkey's egg. The uterus was healthy, as were also the abdominal viscera.

The tumor, when first removed, weighed nineteen pounds, and was larger than the pregnant uterus at full term. On section, it was found to be tough and fibrous in structure, and to have in its interior a few small cavities containing a purulent-looking fluid. One of these cavities, which was larger than the rest, would probably hold seven or eight ounces. The first section,

made directly through the centre of the tumor, did not, however, pass through any of these cavities, but gave the same impression of uniform solidity that the exterior of the tumor had done. The accompanying engraving, taken from a plate of Lebert, with which the tumor in its recent state was compared, so closely resembles its appearance when laid open, that it may be regarded as an excellent likeness of it. A portion of the tumor was sent to Dr. Edward Curtis, microscopist to the Strangers' Hospital, for examination, and its structure is thus described by him: "I found the ovarian tumor to be a firm, solid mass, which on section under the microscope was found to be composed of a dense stroma of fibrous tissue, the bands of fibres being broad and interlacing in every direction, and the cellular elements of the tissue largely developed. Ramifying through the meshes of this fibrous stroma, but in rather scanty proportion, were collections of epithelioid cells, the nests, in the sections, appearing as irregular, long, narrow bands of cells. From this structure the tumor belongs to the category of the carcinomata, the microscopic appearance, in fact, being very like that of many scirrhous cancers of the breast."

True cancer of the ovary of any kind is infrequent, and a solid ovarian cancer of this size is of such very rare occurrence as to constitute it a sort of pathologi cal curiosity.

The nearest approach that I have been able to find to this case, in a hasty examination of the literature of the subject, occurs in Lebert's "Pathological Anatomy," where a description of what is there called an

my

enormous cancerous tumor of the ovary" is given, the tumor weighing eleven pounds. The plate accompany. ing that description so closely resembles the appearance presented by this tumor when first laid open, that it might readily pass for a faithful likeness of it. Although there are several points of interest connected with this case, I shall merely allude to one-the ques tion of diagnosis. Before the patient came under observation, she had already been examined by two experienced gynaecologists, both of whom were of the opinion that the case was one of fibrous tumor of the uterus; and, in view of the exceeding rarity of large, solid tumors of the ovary, I might have entertained the same opinion, in spite of the history of the case, had it not been that, by one of those curious coincidences by which rare cases so frequently occur in couples, I had seen, in consultation with Dr. Willmarth, of Orange, N. J., some three months previously, a case very nearly par allel to this, in which, basing my diagnosis chiefly on what I then supposed to be the fact, that solid tumors of the ovary never attain a large size, I gave it as my opinion that the patient was suffering from a fibrous tumor of the uterus that had grown with exceptional rapidity. In that case the patient was only 24 years old, had suffered from profuse hæmorrhages, and had a tumor of such exceeding density that it was difficult to divest the mind of the notion that it was a fibrous tumor. The examination per vaginam served, too, to strengthen this impression, for the cervix uteri could be traced directly into the mass of the tumor, the continuity of tissue appearing to be perfect. The depreciation of the

woman's health, and the general appearance of cachexia that she presented, I was inclined to attribute to loss of blood. The one thing that I could not reconcile with the diagnosis that I made of fibrous tumor, was the rapid growth of the mass, which had only shown itself some three or four months previously to my seeing the patient.

She died about two months after I saw her, and at the autopsy the uterus was found to be perfectly healthy, but both ovaries were the seat of scirrhous disease, being enlarged nearly equally, and weighing together eleven pounds. The microscopical appearances were almost identical with those already given.

Having the experience of that case to guide me, I had but little difficulty in arriving at a correct diagnosis in this one, but a reference to any of the standard works on gynæcology or general pathology will show how constant is the statement that solid cancer of the ovary seldom grows larger than an orange and very rarely attains the size of a foetal head. It is not surprising, therefore, that the mere size of a solid tumor of this kind should militate against the idea of its being of ovarian origin.

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