A PRELIMINARY REPORT ON 
THE MORPHOLOGY OF OVARIAN 
AND MYOMATOUS TUMORS 
HOWARD A. KELLY, M. D. 
PROFESSOR OF GYNECOLOGY AND OBSTETRICS IN THE JOHNS HOPKINS UNIVERSITY, 
GYNECOLOGIST AND OBSTETRICIAN TO THE JOHNS HOPKINS HOSPITAL, BALTIMORE 
REPRINTED FROM THE NEW YORK JOURNAL OF GYNECOLOGY AND OBSTETRICS 
FOR fUNE, 1893 
NEW YORK 
Stuyvesant Press 
154 AND 156 WEST TWENTY-SEVENTH STREET 
1893 FIG. I. 
The normal abdominal outlines for the sake of contrast with succeeding cases of 
enlarged abdomen. 
FIG. 2. 
An abdomen made scaphoid by the removal of a large fibrocystic tumor. The mass 
is a gauze drain. This shows the reverse of the conditions to be studied. A PRELIMINARY REPORT ON 
THE MORPHOLOGY OF OVARIAN 
AND MYOMATOUS TUMORS 
HOWARD A. KELLY, M. D. 
PROFESSOR'OF GYNECOLOGY AND OBSTETRICS IN THE JOHNS HOPKINS UNIVERSITY, 
GYNECOLOGIST AND OBSTETRICIAN TO THE JOHNS HOPKINS HOSPITAL, BALTIMORE 
REPRINTED FROM THE NEW YORK JOURNAL OF GYNECOLOGY AND OBSTETRICS 
FOR JUNE, 1893 
NEW YORK 
Stuyvesant Press 
154 AND 156 WEST TWENTY-SEVENTH STREET 
1893 FIG. 3. 
Globular distension of the abdomen by an ovarian cyst, seen from below. 
A PRELIMINARY REPORT ON THE MORPHOLOGY OF 
OVARIAN AND MYOMATOUS TUMORS.1 
Howard A. Kelly, M. D., 
Professor'of Gynaecology and Obstetrics in the Johns Hopkins University, Gynaecologist and Ob- 
stetrician to the Johns Hopkins Hospital, Baltimore. 
I will offer no apology for presenting for the consideration of the 
Southern Surgical and Gyngecological Society any facts relative to the 
life history of ovarian and myomatous tumors, affections which are so 
constantly before the members from a severely practical standpoint. 
1 use the word morphology in a broad non-technical sense to 
include changes in the contour of the patient’s body caused by these 
tumors, as well as peculiarities in the form and disposition of the 
tumors themselves. I propose, therefore, briefly to consider certain 
characteristic peculiarities produced in the (a) form of the abdomen, 
(b) peculiarities in the disposition, or packing away of these tumors 
within the abdominal cavity, and (c) peculiarities of form assumed by 
these tumors in so far as they are affected by the constraining con- 
1 Delivered at the meeting of the Southern Surgical and Gynaecological Society at 
Louisville, Ky., November 16, 1892. Howard A. Kelly, M. D. 
4 
stricting influences of their environment; in other words the extent to 
which they are capable of being moulded by the pressure of neighbor- 
ing structures. 
(a) Characteristic Traits Evident Upon Inspection of the Abdomen. 
The general tendency of tumors growing out of the pelvis and 
extending up into the lower part of the abdomen is to produce marked 
distension of the lower abdominal zone, at once evident to the eye, and 
readily recorded by measuring the distance from the umbilicus to the 
fig, 4. 
Marked example of the globular distension of the abdomen by an ovarian cyst in 
an old woman. 
anterior superior spines and symphysis, which is increased beyond the 
normal, while the distance from the umbilicus to the sternum and ribs 
remains proportionately but slightly, if at all, changed. This generic FIG.S. 
The large bosses of an ovarian cyst in a young girl. The tumor seen in profile. 
FIG. 6. 
A quartering view of the tumor shown in profile in Fig. 3, showing the large bosses. 6 
Howard A. Kelly, M. D. 
difference I will demonstrate by comparing a group of tumors, arising 
from the upper part of the abdomen, with a pregnancy eight months 
advanced, taken as a type of tumors arising from below. 
The form of abdomen characteristic of large ovarian cysts is a glob- 
ular or ovoid distention of a part or the \yhole of the abdominal wall, 
pushing out the infra-umbilical portion much more than the supra- 
umbilical, at least so long as the tumor occupies the lower half or two- 
FIG. 7. 
This patient has a large polycystic ovarian tumor. She is in addition excessively 
fat. The great distension of the upper abdominal zone is evident and 
characteristic of the obese. 
thirds of the abdomen. This enlargement is uniform in parovarian 
cysts and polycystic tumors exhibiting but few bosses, due to the fact 
that the latter are composed of one or two large cysts associated with 
a mass of smaller ones, and the large cyst is best accommodated in the 
median line in the distended concave anterior abdominal wall, while The Morphology of Ovarian and Myomalous Tumors. 
7 
FIG. 8. 
The same patient shown in Fig. 5 after removal of the tumor. The difference in 
outline is simply the patient minus the tumor. 
the smaller ones lie in the flanks and consequently do not show on the 
surface. 
The alate or winged-shaped chest is due to a pushing out of the 
lower ribs, and is a characteristic of any mass big enough to distend the 
entire abdominal cavity. 
Prominent exceptions to the general rule just enunciated that pelvic 
tumors distend most markedly the inferior abdominal zone are the 8 
Howard A. Kelly, M. D. 
notable stretching of the upper abdomen in very fat women with large 
ovarian tumors, and the like distention of the abdomen in rhachitic 
dwarfs in advanced pregnancy. 
Myomata being less yielding retain more prominence in the median 
line, and often look like a pregnant uterus, striking differences, how- 
ever, are the breadth of the tumor and a peculiar abruptness in its 
upper outline. 
fig. 9. 
Shows well the vertical outlines of a myomatous uterus. Note especially the upper 
border. 
Nodular Myomata on the other hand stand out in marked contrast 
to the smooth outlines of cystic tumors in giving to the lower abdomen 
a lumpy bossed appearance, thus exhibiting through muscles and skin 
a softened exaggeration of their irregular outlines. This peculiarity 
still remains prominent although softened, after these tumors have 
undergone fibro-cystic degeneration. 
The contrast of the globular outline of the ovarian tumor with the 
more or less bossed appearance of a large fibro-cystic tumor is well 
shown in one of our photographs. 
The flattened ovoid of an ascites, which is no tumor, shows well the 
striking difference between an enlargement contained in its own sac 
wall and one free and without definite form in the abdominal cavity. 
It is well to bear in mind, however, that occasionally a simple The Morphology of Ovaria?i and Myomatous Tumors. 
9 
ascitic accumulation will distend the abdomen prominently in the 
median line, presenting a deceptive appearance, a close mimicry of the 
encysted tumors. 
(b) The Disposition of Tumors in the Pelvis and Abdomen follows the 
Laws of Accom modation. 
The problem presented is that of a body with a smooth surface and 
■of varying degree of mobility, contained within an irregular cavity 
with a smooth lining and subjected to frequent movements of succus- 
sion—-the law is, that the body in question finally assumes a position 
best adapted to its form, subject to the single restriction of its attach- 
ments or adhesions. 
Small ovarian tumors up to the size of a goose egg commonly lie on 
the same side from which they originate. 
fig. 10. 
The uterus from the patient seen in Fig. 8. The ovarian tubes are seen on either 
side. FIG. 11, The Morphology of Ovarian and Myomatous Tumors. 
11 
fig. 12. 
A myomatous uterus lifting the lower abdominal zone forward. The hazy line from 
the umbilicus to ensiform is diagnostic, as it shows by contrast the splinting 
of the lower abdominal zone by the tumor. 
FIG. 13. 
The nodular outlines of a large fibrocystic tumor. 
Upon continuing to grow, the cyst at first extends over on to the 
opposite side of the pelvis, and then proceeds to enlarge upwards into 
the abdominal cavity. As soon as the cyst leaves the side on which it 
originated, it commences to put traction upon its pedicle thus pulling 12 
Howard A. Kelly, M. D. 
FIG. 14. 
The same fibrocystic mass lifted out on to the abdomen and before removal. 
the uterus towards that side. By thus shortening one fornix the 
opposite fornix is made wider, and the tumor is thus in this case more 
easily palpated through the vagina on the opposite side to its attachment 
and the natural but erroneous inference in attempting to locate it is 
that it is a right or a left sided tumor according as it is felt more easily 
on the right or left side. 
The facility with which the simpler monocystic and some jelly-like 
tumors accommode their form to their surroundings may be well seen 
by noting the effect of gravity outside the body, where they at once 
■collapse into a flattened ovid mass. 
In the body such cysts as well as the softer myomata often fill 
the pelvis and bud out into the abdomen until they assume the 
shape of a gourd or a clove with short stem and big head. Within the The Morphology of Ovarian a?id Myomatous Tumors. 
abdomen they are ovoid or flattened ovoid, according to the distension 
•of the sac. 
Cystic tumors filling the pelvis and a part of the abdomen are rarely 
found to originate in some upper abdominal tumor. I have here for 
■demonstration a photograph of an enormous kidney, containing over a 
gallon of pus, extending from the pelvic floor up through the abdomen 
and pushing up the left ribs. 
Polycystic ovarian tumors, left to grow until they extend above the 
umbilicus, if not detained by adhesions, are most apt to lie markedly 
■displaced to the right side. The explanation of this peculiarity is the 
same as that I have suggested for the right obliquity and torsion of the 
uterus in advanced pregnancy. The tumor is simply displaced over 
A paunched abdomen containing neither fluid nor tumor, but closely resembling an 
ovarian cyst. 
fig. 15. FIG. 16. 
The flattened abdomen of an ascitic accumulation due to carcinosis of the peritoneum, The Morphology of Ovarian and Myomatous Tumors. 
<on to the right side by the stomach, for the repeated soft impacts of the 
■constantly alternately enlarging and contracting stomach are far more 
potent than the tendency of gravity to keep it forward in the median 
line, or the tendency of the movements of the patient to dispose of 
it in some other position. For the same reason in big ovarian tumors 
fig. 17. 
The lump seen on the right side is a dense myoma uteri, the larger portion of which 
is wedged in the pelvis. 
an enormous sac will sometimes be found directly under the concavity 
of the liver snugly fitting convexity into concavity. This dextro-posi- 
tion of the tumor will not be apparent on the surface before opening 
the abdomen, when a distended stomach compensates the inequality, 
and gives the surface a uniformly rounded appearance. 
The disposition of the intestines ifl the case of tumors rising from 
the pelvis is peculiar and worthy of note. They are at first crowded 
up above away from the front, and then out into the flanks. The 
omentum and transverse colon lie in front of or across the upper part 
of the tumor, which thus, almost always remains infra-omental. 
The disposition of myomatous tumors is interesting. Not infre- 
quently one or more remain fixed in the pelvis where they grow until 
they choke vital organs and threaten the life of the patient. There is 
a peculiar sort of myoma often met, which tends especially to occur FjG. 18,—The abcjonjen shown in Fig. 16 but here shown from a quartering view. Thejiark spotjs the umbilicus. The Morphology of Ovarian and Myomatous Tumors. 
17 
in women who have borne children when they develop myomata, 
appearing as a more or less uniform enlargement of the whole uterine 
body, assuming the appearance and characteristic position of the 
pregnant uterus, bellying out the abdominal wall in the median line in 
front. 
(0) Form Changes in the Tumors Themselves. 
Multiple myomata usually lie like saddle-bags hanging one on 
either side in the iliac fossae and the groins, this is due to the more or 
less rigid linea alba which always tends to find the sulcus between two. 
tumors. 
Although myomata are among the densest tumors met with, they 
often show the impress of the structure with which they have been in 
constant contact during their growth, in a remarkable way. Thus, I 
have seen a distinct sulcus about sixteen cm. long, caused by the con- 
stant pressure of the linea alba running up the length of a large tumor. 
Of course, upon extirpating the tumor I observed the sharp unyielding 
fibrous linea exactly fitting this sulcus, and noted further that the 
sulcus did not simply arise from the junction of two myomatous 
nodules. 
FIG. 19. 
The same patient shown in Fig. 18, with the tumor lifted up out of the abdomen 
but not removed. The top of the tumor in the picture rested on the floor of the 
pelvis. The nodule near the operator’s right hand caused the prominence on the 
skin in Fig. 18. 18 
Howard A. Kelly, M. D. 
FIG. 20. 
A profile view of the tumor seen in Fig. 19. The upper nodular mass lay free in 
the abdomen. The lower mass is a myomatous cast of the pelvis. The right side 
exactly fitted the sacral curve in the median line. Suppressed nodules are seen on 
the,surface of this tumor. 
Again, I have seen a broad myoma with its back broken, as it were, 
bent over the promontory of the sacrum and the lower lumbar vertebrae, 
showing upon removal on its posterior surface an exact mould of the 
broad vertebral ridge. 
To show how fruitful and interesting such observations may become 
the following points of interest were culled in one day out of four 
coeliotomies (abdominal sections) for myomata, in the first case the 
nodule was small lying in the posterior surface of the uterus near the 
fundus, which it had toppled over causing a retroflexion; in the second 
case the myomatous uterus was of the size and form, with the exception 
of a little greater breadth, and almost of the consistency, of an ad- 
vanced pregnancy. Another case was a large subserous fibro-cystic 
tumor filling the pelvis and rising up into the abdomen as if it had 
overflowed the pelvis like molten wax. The remaining case, a 
multinodular myomatous mass, proved most interesting from the stand- 
point of this investigation. The tumor had formed a dense attachment The Morphology of Ovarian and Myomatous Tumors. 
by one of its nodules, to the rectum low down in the pelvis. The 
rectum, however, was displaced and dragged over into contact with the 
right pelvic wall. This anomaly could only be explained by assuming 
that the myomatous nodule had originally occupied a position in the 
median line where it adhered to the rectum, and later in some way it 
had become rotated to the right and dragged the rectum with it. This 
interpretation was borne out by the further observation that the body 
of the large uterus reaching up to the umbilicus was rotated one-fourth way 
around from right to left, so that the right tube and ovary lay under 
and parallel to the linea alba. This dextrotorsion of the uterus was 
explained by the fact that the linea alba lay in a groove about two cm. 
deep between two large fibrous nodules, the only masses found on the 
fundus, one in front, an old hard white nodule about five cm. in diameter, 
FIG. 21. 
The same tumor shown a posteriori. The breadth of the tumor is the breadth of the 
pelvis, and the surface visible is a cast of the surface of the posterior half of the 
pelvis including the sacral hollow. 20 
Howard A. Kelly, M. D. 
and one posterior, redder and more succulent, about eight cm. in diame- 
ter. The explanation is briefly this: Originally there were two prominent 
nodules, one anterior at the fundal extremity, and one posteriorly at 
the cervical extremity. The latter became adherent to the bowel. 
Later a large nodule developed posteriorly at the fundal end, and grow- 
ing rapidly, pushed the uterus up out of the pelvis and pushed the 
mass anterior to the fundus forward until it came under the fibrous linea 
alba, which, striking its smooth convex surface, deflected it to the left 
side, thus rotating the uterus and dragging the cervical nodule with the 
rectum over to the right side. 
In this explanation I am confirmed by her physician. Dr. Hilde- 
brandt, of Pennsylvania, who has kept her under close observation for 
FIG. 22. 
several years, that the big mass on the right side, has been noted both 
by himself and the patient as of recent growth. 
One of the most remarkable and yet not uncommon instances oi 
this adaptation to environment is shown by a case still in the ward 
at The Johns Hopkins Hospital. An unusually dense myomatous 
mass choked the whole pelvis, and after opening the abdomen was 
extracted with patient persistence and the use of considerable force, 
and only after partly breaking it off from its pedicle near the fundus, 
although there were no adhesions. Its attachment with that of several FIG. 23. 22 
Howard A. Kelly, M. K>. 
other nodules was near the fundus, but this particular nodule had been 
caught in its growth beneath the promontory of the sacrum where it 
continued to develope until all the pelvic viscera were compressed and 
the patient reduced to a pitiable condition. You will observe in the 
photograph the irregular anterior surface adapted to the cervix and 
lower part of the body of the uterus; the posterior surface, however, is 
as exact a model of the sacral concavity as could be obtained by 
pouring plaster into the pelvis and filling it from floor to brim. This 
is beautifully shown both in profile and full view taken from behind. 
This brief study is only intended to be suggestive. One of its 
objects is to stimulate closer observation of details in these important 
cases which we are now-a-days handling in such wholesale fashion.