Chapter XVIII: Front Matter (18)

Twisting of the pedicle of an ovarian tumor by axial rotation is another serious complication, which leads to its strangulation and gangrene, with consequent fatal peritonitis. The chief factors of this accident are, probably, the filling and emptying of the bladder and rectum, which may rotate an unadherent cyst with a long stalk. The symptoms of axial rotation, as carefully noted by Tait[26] and Aronson,[27] are sudden accession of severe abdominal pain and tenderness, a rapid increase in size, and incessant vomiting, the matter thrown up soon becoming green. The pulse rises, but the temperature is not always affected, and rigors are absent. Such a train of symptoms should lead at once to the abdominal section.

[Footnote 26: _London Obstet. Trans._, vol. xxii. p. 97.]

[Footnote 27: _American Journal of Obstet._, Nov., 1883, p. 1211.]

DIAGNOSIS.--The diagnosis of ovarian cysts is often beset with so many difficulties that very humiliating blunders have been made by the best surgeons of the day. Lizars of Edinburgh performed laparotomy on a woman in order to remove a suspected ovarian cyst, and found nothing but fat. Others have done the same thing, and to their dismay have discovered merely an accumulation of wind in the intestines. The great Dieffenbach once opened the belly of a woman for supposed extra-uterine pregnancy, and found neither fat nor wind--not even, indeed, a trace of a tumor. Once an enormously distended bag of waters {305} broke just as a deservedly eminent British surgeon had rolled up his sleeves and was about to wheel his patient into an amphitheatre crowded with spectators to witness an ovariotomy. A surgeon of whom Great Britain can well be proud once drove his trocar into the shoulder of a foetus under the idea that he was tapping one of these cysts. These facts show the importance of knowing how to make an examination for a suspected ovarian cyst, and how to distinguish such a cyst from other tumors and other fluid collections in the abdominal cavity.

The usual history of an ovarian cyst is--a tumor first discovered in one groin, rapidly enlarging, without tenderness or soreness, giving no inconvenience save from its bulk. The general health remains good until the tumor begins to distend the abdomen; then emaciation takes place, the strength becomes impaired, and the features begin to assume that pinched expression described on a preceding page as the facies ovariana. By inspection and palpation there will be found an elastic but somewhat irregular tumor, yielding the sense of fluctuation. By percussion a dull sound will be elicited at every point, except in the flanks, which are more or less resonant. If the contents of the tumor are colloid or the tumor is thick-walled or very tense, the sense of fluctuation may be either obscure or wanting. Sometimes a feeling like that of fluctuation is conveyed by a fat-laden wall of the abdomen. To muffle this fat-thrill the ulnar edge of the hand of an assistant is laid along the linea alba while the surgeon percusses the abdomen. The pressure thus exerted acts precisely like the damper-wedge of the piano-tuner, which muffles the sound of one string while its fellow is being tuned. By these means fluctuation can be detected and the diagnosis of a collection of fluid unhesitatingly made out.

By the amount of solid and fluid portions of a cyst correct diagnosis can often be made out, whether it is simple or multiple, compound or proliferous; but this is a matter of comparatively little practical importance, because when once a growing tumor has been ascertained to be ovarian, its removal must follow as a matter of course.

There are, however, certain enlargements or tumors of the abdomen which are very liable to be mistaken for an ovarian cyst, and to these, in the order of their frequency, we shall call attention.

Ascites.--When the fluid is not encysted, but free, as in ascites, it is at liberty to go to the most dependent portions of the body. Hence changes in the posture of the woman will make corresponding changes in the level of the fluid. These level-changes are made evident by percussion. When the woman lies on her back the intestines float up to the surface, and the fluid gravitates to the flanks, making them bulge. In other words, percussion in the dorsal position elicits a clear note in the umbilical region and a dull note in each flank. In this posture the front surface of the abdomen is symmetrical and somewhat flattened. But when the woman sits up the belly becomes convex. Further, ascitic fluid is displaceable by pressure on the abdomen. But even these signs are not always trustworthy, because the intestines, glued down by adhesions, may not float up, and there will be dulness over the front of the abdomen, or a distended colon may make each flank resonant. For instance, I have known a papillary cancer of the omentum attended with dropsy of the abdominal cavity to give such signs of ovarian cyst as dulness in front and resonance {306} in the flanks. When the fluid is ascitic the floating or false ribs are not pushed outward. The womb is usually low down and movable; there will also be more or less of bulging in Douglas's pouch.

On the other hand, in an ovarian cyst the womb is usually not very movable, and it is displaced to one side, generally behind the cyst. While the woman lies on her back the front surface of the abdomen is convex and unchanged in form. The floating ribs bulge out, making the chest conical. There will also be dulness in the front wall over the tumor, but usually more or less resonance in the flanks and over the region of the stomach: this clearness on percussion has been aptly termed coronal resonance. These areas of dulness and of resonance remain constant whatever the posture of the woman. Yet in suppurating cysts or after a careless tapping, or in cysts communicating with the intestine, the sac may contain gas, which will give a tympanitic sound over all the elevated portions of the abdominal surface.

It must, however, be borne in mind that ascites may exist concurrently with an ovarian cyst, and especially if the tumor be malignant in character. This can usually be detected by deep palpation, when the cyst will be reached and recognized by the fingers; or by pressing lightly, and then more firmly during percussion, an upper and a lower stratum of fluctuation will be detected.

Pregnancy.--The question of pregnancy is a very serious one, for it is sometimes a most difficult one to decide, especially when dropsy of the amnion (hydramnios) exists. In making a diagnosis nothing must be taken for granted, not even the woman's statement. She may be mistaken, or, indeed, she may be wilfully deceiving in the hope of having a cheap abortion induced by the examination. She may be pregnant and yet menstruate. On the other hand, an ovarian tumor will sometimes arrest menstruation. A healthy, ruddy complexion coexistent with abdominal enlargement should always excite a suspicion of pregnancy. There is sometimes a jaded look in pregnancy--the facies uterina--but never the facies ovariana.

The various signs of pregnancy should be searched for, especially ballottement and the foetal heart-sounds. The cervical region should be most carefully examined per vaginam. A good broad rule to remember is, that when the womb is gravid the cervix is as soft as one's lips; when it is empty the cervix is as hard as the tip of one's nose. In all doubtful cases any operation should be postponed until time has revealed the true condition of things. Of course the introduction of the sound will settle the question of pregnancy, but this procedure is not to be thought of when any doubt exists, and it is therefore useless as a diagnostic agent. An ovarian tumor may coexist with pregnancy, and may have to be tapped or be extirpated before the delivery of the woman. The history of the case, the unusual size of the abdomen, the sulcus between the two tumors, will generally reveal the condition.

Fibroid Tumors of the Womb.--These tumors often reach a very large size, and if of the soft variety give an obscure sense of fluctuation which so closely resembles that of a colloid ovarian cyst or of a tense thick-walled cyst as to make the differential diagnosis very puzzling. The hard myoma gives no sense of fluctuation, but, on the other hand, if pedunculated it can be very readily taken for a solid ovarian tumor. A {307} fibroid tumor of the womb can very generally be told by the history of menorrhagia, by its slow growth, by the uterine souffles and colics, by the effacement of the cervix, and by the tumor being felt to be continuous with the cervix and inseparable from the womb. Then, again, women burdened with a fibroid tumor so far from losing flesh usually become more fat, and their complexion, like that of many pregnant women, is mottled with patches of brown pigment. Further, the uterine cavity is usually much longer than natural, and when the tumor is moved from side to side the motion is communicated to the sound passed within the cavity. But every rule has its exceptions, for when an ovarian cyst has a close attachment to the womb the latter may become elongated and also follow the movements communicated to the tumor.

The positive diagnosis between an ovarian cyst and a fibro-cystic tumor of the womb is impossible, but, fortunately, the latter disease is exceedingly rare. The existence of the latter may be inferred if the woman's face has a jaded appearance and is disfigured by brown patches--the facies uterina--if the growth of the tumor has been very slow, and if the womb is implicated with it. After tapping there will be a partial collapse of the tumor, and the fluid withdrawn is usually bloody and it coagulates on being cooled. After an exploratory incision the tumor presents to the eye a dark-blue and vascular capsule covered with interlacing fibrous bands.

Renal Cysts.--Cysts of the kidney are very commonly mistaken for ovarian cysts. I have made this mistake, and it was not until after breaking up adhesions and emptying the cyst that I discovered the character of the tumor. It was successfully removed. Renal cysts start from below the floating ribs and extend downward and forward, while an ovarian cyst begins from below and grows upward. The former, being generally caused by impaction of a calculus in the ureter, are usually associated with urinary disturbances. They also push the intestines before them, which give a resonant sound on percussion, while the contrary holds good with an ovarian cyst. Since the transverse colon lies between the cyst and the liver, the line of resonance caused by it will show that the cyst is not hepatic. The fluid withdrawn from a renal cyst contains urea and the other constituents of urine, but the urinous odor will be either very faint, or, as in my case, wholly absent. It may as well be stated here that when renal cysts present great difficulties in the way of their removal, they had better be treated by a large drainage-tube.

A floating kidney may be mistaken for a small ovarian tumor. But the latter has a pelvic attachment and can readily be pushed down into the basin, while the former is kept from being pushed very low downward by an upper attachment. Again, the floating kidney usually keeps its peculiar shape, and it is frequently lost by slipping from under the fingers into its natural bed in the flank.

Spina Bifida.--Strange as it may seem, this spinal cyst, when internal on account of a deficiency in the anterior parietes of the lower vertebræ, has been mistaken for an ovarian or a parovarian cyst. I am cognizant of two such errors of diagnosis made by two distinguished gynecologists. In each the sac was emptied by the aspirator, and the patient perished shortly afterward with the same kind of cerebral symptoms which follow the sudden withdrawal of the fluid from the cavity of an external spina bifida.

{308} Phantom Tumors.--In the diagnosis of an ovarian cyst one must be on guard not to mistake for it a phantom tumor. In this imaginary kind of tumor, which hysterical women have the knack of creating, the whole belly will be uniformly distended to the size of the gravid womb at term. This is caused partly by flatus and fat, and partly by the arching forward of the spinal column, with the recti muscles drawn so tense that they cannot be indented. I have frequently had patients with this kind of abdominal enlargement sent to me from a distance, under the impression that it was due to some kind of tumor. But the diagnosis is easily made from the uniform resonance all over the belly; if, moreover, the patient's attention be engaged by conversation, the rigidity of the recti muscles disappears, the abdomen becomes flaccid, and the hand can be made to sink in so as to feel the spine. In very nervous women it may be needful to administer an anæsthetic, when all the tokens of a tumor will promptly disappear.

Obesity.--A large accumulation of fat on the abdominal wall and in the omentum has frequently given rise to the suspicion of the existence of an ovarian cyst. This condition occurs, usually, at the climacteric, and on percussion the vibratile thrill of the fat-laden wall of the abdomen conveys a very misleading impression of fluctuation. Further, to add to the difficulty, if the layer of fat be a very thick one, the abdomen, instead of being resonant on percussion, yields a dull note. But in obesity the fat is not limited to the abdomen, for the breasts, face, and limbs partake of the general enlargement. The abdominal wall hangs in folds when the sitting posture is assumed, and the umbilicus is indented and not protuberant. My own method of making the diagnosis is to grasp the abdominal wall with both hands and ascertain the amount of fat. When this amount is excluded, there will not be found room enough behind it for a tumor of any size, and the enlargement will thus be satisfactorily accounted for.

A dilated stomach, cystic tumors of the omentum, and encysted abscesses of the peritoneal cavity, and, indeed, of the abdominal wall, have been mistaken for ovarian tumors; but these are very exceptional cases. In all doubtful cases an exploratory incision should be resorted to.

SURGICAL TREATMENT OF OVARIAN CYSTS.--In the consideration of this subject it may be divided into the palliative treatment and the radical treatment.

Palliative Treatment.--Tapping either by the trocar or by the aspirator comprises the only palliative treatment of ovarian cysts; yet, as a broad rule with but few exceptions, an ovarian cyst should not be tapped. The objections to this operation are--that, slight as it may seem, it is by no means devoid of danger. Even when the smallest hollow needle of the aspirator has been used inflammation of the cyst may follow, which will compel the immediate resort to ovariotomy and very greatly compromise the success of this radical operation.[28] This has repeatedly happened--once in one of my own cases, in which, however, the removal of the cyst saved my patient's life. Further, the fluid of a polycyst is usually acrid--so much so sometimes as to irritate the hands of the operator--and the escape of a few drops into the cavity of the peritoneum may set {309} up a violent and rapidly fatal peritonitis. Then, again, a fatal hemorrhage may take place from some wounded vessel, either in the cyst-wall, or in the adherent omentum, or in the vascular pedicle which may lie spread out in front of the cyst-wall, or, indeed in the abdominal wall itself, for the vessels here are often varicose from impeded circulation. In the fourth place, adhesions are very likely to form after tapping. Fifthly, innumerable child-cysts, which were very small before the tapping, being now relieved from pressure are liable to take on rapid growth and make the tumor more solid; and the more solid the cyst the longer the incision needed for its removal. Sixthly, in polycysts not only are the dangers attending the operation enhanced, but the cyst rapidly refills, and the woman becomes exhausted by the drain on her system. At the very best, 2 per cent. of cases of tapping in polycysts are fatal, even when performed by the most skilled specialists. Seventhly, a cyst once tapped rapidly refills, and soon needs repetitions of the operation. This drain on the system quickly tells upon the woman, and she is sometimes left too weak to have the radical operation performed. The first tapping, indeed, greatly hastens on this crisis, and it should therefore be put off as long as possible. Eighthly, a cyst emptied by tapping tends to rotate on its axis, and torsion of the pedicle may result, ending in gangrene and peritonitis. Ninthly, repeated tappings tend to convert benign papillary growths into malignant. Finally, Lawson Tait[29] draws attention to the fact that "repeated tappings deprive the blood of some element or elements included in the infinite variety of albuminous substances found in ovarian cysts, the deficiency of which predisposes to coagulation of blood." Hence after the removal of the cyst deaths have been "due to the formation of a firm white clot which started from the point of ligature of the pedicle, and slowly traversed the venous system until it reached the heart, death ensuing in from thirty to forty hours after the operation. The symptoms which precede death are swelling of the legs, rapid rise of the pulse, and its disappearance from the extremities some time before death, and breathlessness, ending in suffocation and slight delirium." He has met with several such cases of venous thrombosis starting from the pedicle, and they all occurred in patients who had been previously tapped. There are, however, cases in which tapping cannot be dispensed with; for instance--

1. Many women with ovarian tumors, having heard of cases of abdominal effusion or of cyst in which tapping was followed by a cure, will not submit to the radical operation until repeated tappings have proved to them the futility of the trocar.

2. Cysts of the parovarium and of the broad ligament being often cured by the use of the trocar, it is proper to try the effect of one tapping in slow-growing, unilocular, thinned-walled, and flaccid cysts, which thus exhibit the chief characteristics of these extra-ovarian cysts.

3. When an ovarian cyst develops during the later months of pregnancy, it will often be best to resort to tapping in order to relieve the woman from the pressure of two growing organs and enable her to go to full term. Sometimes labor is made impossible by the presence of a cyst, which will then have to be emptied.

4. In very large tumors which by pressure interfere with the functions of the kidneys, heart, and lungs, thereby causing albuminuria, oedema, or {310} dyspnoea, tapping is a useful prelude to ovariotomy. By the relief from pressure afforded to these organs not only will the liability to shock be lessened, but also to hemorrhage, for vessels previously varicose will now contract to their natural calibre.

5. In cases of doubtful diagnosis or in those in which from malignancy, from formidable adhesions, or from other circumstances the radical operation is deemed impracticable, tapping in the first case may clear up the diagnosis, and in the latter ones will prolong the patient's life. But it must always be borne in mind that in a few weeks the fluid will reaccumulate, and the operation will have to be repeated, rapidly exhausting the patient by the drain on her system. It is well, therefore, to put off the first tapping as long as possible.

[Footnote 28: _American Journal of Obstetrics_, Nov., 1883, pp. 1169 and 1189; also _Transactions American Gynæcological Society_, vol. ii., 1877, p. 270.]

[Footnote 29: _Midland Medical Society, Lancet_, Feb. 18, 1882.]

Tapping may be performed through the abdominal wall, through the vagina, or through the rectum, but, for reasons which will presently be given, the first mode is decidedly the best.

Tapping through the Abdominal Wall.--For this operation either the aspirator may be used or else Wells's trocar with a long rubber tube attachment. Of the two, I much prefer the former. In aspiration, after the bladder has been emptied, the woman lies on her back close to the side of the bedstead with her abdomen exposed. The preferable site of puncture is in the linea alba midway between the navel and the symphysis pubis; that is to say, at a point where the tissues, being tendinous, are most free from blood-vessels, and where the omentum is most out of the way. But if at this point the tumor feels solid, or an underlying knuckle of intestine is discovered by percussion, or the vessels look varicose, any other place in the abdominal wall may be selected where fluctuation is most manifest, provided it lies below the level of the navel. The reason for choosing a low site for the puncture is, that if the hollow needle be plunged in at any point above the navel it will slip out of the cyst as the latter collapses and before it is wholly emptied. The skin is now thoroughly cleansed with soap and water and washed with a 5 per cent. solution of carbolic acid. The painful part of the operation being the penetration of the skin, the selected place for puncture should either be frozen with the ether spray or be benumbed by a lump of ice dipped into some table-salt. After the aspirator-jar has been exhausted of air the hollow needle or canula, armed with its stilette, is lubricated with carbolated oil or vaseline, and rapidly plunged deeply into the cyst. Should the cyst not wholly collapse, the canula has probably become obstructed, and it should be cleared out by one of the blunt stilettes which are made of different sizes to fit the different canulas. Sometimes the flaccid walls of the sac as it becomes empty are sucked up into the end of the canula, and the flow of fluid is suddenly arrested. This accident is recognized by a peculiar valve-like vibration communicated to the instrument, and is overcome by raising up the end of the canula or by directing it to another part of the cyst. Should, on the other hand, other cysts present themselves, they can be emptied without withdrawing the canula by reintroducing the stilette, and by directing its point to each cyst in succession. When the fluid ceases to flow the fore finger and thumb firmly compress the fold of the abdominal wall behind the canula as it is withdrawn, so as to avoid the entrance of air, and the small puncture is covered by a piece of adhesive plaster. A pad of cotton wool is now laid over the {311} scaphoid abdomen and a flannel binder applied. These afford a grateful feeling of support and take away that sense of goneness which is likely to occur. To avoid all risks of inflammation the patient must keep her bed for three or four days and eat sparingly.

When Wells's or any other large trocar is used, the operation should be performed under the spray and with every antiseptic precaution. The skin should be previously incised with a lancet, and, lest air should be sucked up into the sac, the free end of the rubber tubing should touch the bottom of the bucket, so as to be always immersed in the escaping fluid. This rubber tubing acts as a syphon with great suction power, and the cyst is more rapidly emptied by Wells's trocar than by the aspirator. Yet I cannot help believing that the latter by its small size is by far the safer instrument, and I always use it when a simple tapping is aimed at. Should any stubborn bleeding follow the removal of the canula, a harelip pin may be passed across the wound deeply enough to get below the wounded vessel, and compression made by a turn or two of silk ligature around the pin. The same means are to be adopted to stop the oozing of fluid which sometimes takes place when a cyst with colloid contents cannot be wholly emptied by the trocar. For it is highly prudent under such circumstances to stop the oozing, as some of the fluid is sure to get into the cavity of the peritoneum, with very generally fatal effects. In such a case the pin ought to include the lips of the wound in the cyst. To avoid as much as possible the escape of irritating ovarian fluid into the cavity of the abdomen, the cyst when tapped should always, if possible, be wholly emptied. This is a rule without an exception. It is therefore very bad practice to remove even with the hypodermic syringe a few drops of the fluid for microscopic examination. Several cases of death from this cause have been reported.[30] I lay stress on this point because in my _Lessons in Gynæcology_ I advocate the practice.

[Footnote 30: _American Journal of Obstetrics_, April, 1876, p. 146.]

Tapping through the Vagina.--This operation is sometimes a very tempting one to perform when one of the cysts of a polycyst is pressing downward behind the bladder and causing dysuria. But it is by no means so safe as the supra-pubic mode of tapping. The reasons for this are--(_a_) The vessels are larger and lie closer together in the lower wall of the cyst near the stalk; (_b_) in a polycyst the larger cysts, growing where they have most room, usually develop in the abdominal cavity, while the more solid portion remains below in the pelvic region; (_c_) other organs, such as the bladder, womb, and rectum, are liable to become dislocated and lie in the track of the trocar; (_d_) the roof of the vagina responds to every respiratory movement of the diaphragm, and a cyst low down is not, from pelvic adhesions, so likely to collapse when tapped as one higher up: hence the cyst is liable to act as a pair of bellows, sucking in air and forcing it out. This inevitably causes suppurative inflammation with all its attendant evils. For these reasons this mode of tapping is never resorted to, except in cases of pelvic adhesion or in those in which the cyst starts from the lower side of the broad ligament and grows downward. Even then it is done only to relieve the distress caused by the double pressure upon bladder and rectum. In such cases the aspirator should be used, as it lessens all the risks. Should suppurative inflammation set in, the sac must be again emptied, the wound kept open by a {312} drainage-tube, and the cavity thoroughly cleansed by daily injections of antiseptic fluids.

Tapping through the rectum has long ago been abandoned by the profession, as it ought to be, except in some very rare cases of atresia vaginæ. It was at one time supposed to possess advantages over the vaginal method, because the subsequent offensive discharges could be retained at will like the other contents of the bowel. But the cavity of the sac always became distended with fecal gas, and fatal septicæmia was pretty sure to set in.

Radical Treatment.--Tapping, followed by the injection of iodine into these cysts, has sometimes been rewarded with a cure, and at one time this mode of treatment had very warm advocates. After the cyst is wholly emptied by aspiration the action of the instrument is reversed, and from two to ten ounces of the officinal tincture of iodine are thrown in. The tincture is used of full strength, because the residual fluid in the cyst will be enough to dilute it. The cyst-wall is next kneaded, and the patient made to turn from side to side and from back to chest, so that the tincture may come in contact with every portion of the secreting surface of the cyst. The fluid is then pumped out, but all cannot be brought away; enough usually remains behind to produce some slight constitutional disturbance. While the canula is being withdrawn, in order to prevent the escape of any of the irritating injection into the abdominal cavity the thumb and fore finger are made to grasp the fold of abdominal wall at the puncture-site and to press it firmly down on to the collapsed cyst-wall. Good and lasting cures have followed such a treatment; but since they can happen only in monocysts, which are almost always parovarian, and not ovarian, it is probable that the mere emptying of the cyst would have done as much. In polycysts such a treatment is not to be thought of, for it would be attended with far more hazard than even the operation of ovariotomy. At the present day injections of iodine are practised only by physicians who do not operate; ovariotomists never resort to them.

Tapping, followed by enlarging the wound in the cyst, stitching its edges to those of the abdominal wound, and permanently keeping it open by tents or by a large drainage-tube, has frequently been attended with success. But since extensive and prolonged suppuration must inevitably ensue, this operation has proved to be a far more dangerous one than that of ovariotomy. It should, therefore, not be resorted to excepting in cases of cysts which are too adherent to be removed. The after-treatment consists in treating the case precisely as if it were an abscess. The cyst is kept empty by draining, and sweet by such deodorizing agents as solutions of iodine, carbolic acid, potassium permanganate, and the liquor sodæ chloratæ. Early this year I had one such case, a patient of C. A. Currie, in which the cyst was wholly adherent to all the pelvic organs and structures, and had besides a communication with the bladder. Not daring, under such circumstances, to remove it, I treated it successfully by incision, drainage, and disinfecting injections; but it was a long time before the drainage-tube could be removed and the woman be released from her bed. Cases, indeed, have occurred in which six months elapsed before the drainage-tube could be taken out and the woman pronounced well.

Another exception in favor of this operation may be made in the case of small cysts growing downward and bulging out the hind wall of the {313} vagina. It may then be advisable to follow Noeggerath's plan. He snips open the vagina transversely behind the cervix to the length of one inch, and makes a corresponding incision in the cyst-wall. The edges of the two incisions are then stitched together and a drainage-tube put in. Thus, the cyst is left with a free and permanent opening into the vagina, through which such antiseptic solutions as have been noted above are thrown up. In time the collapsed cyst-walls adhere to one another and cease to secrete.

Electrolysis has of late also been lauded as a sure and harmless remedy for these cysts. But a careful examination of the subject made by Mundé shows that this agent has been greatly overrated as a specific, and that it "can in no wise supplant ovariotomy."[31]

[Footnote 31: _Transactions American Gynæcological Society_, vol. ii. p. 435.]

Rupture of ovarian cysts has occasionally taken place, either through over-distension or through such violence as a rude fall or an upset from a carriage. This accident, if the tumor were a monocyst or if the fluid happened to be bland, sometimes ended in a lasting cure. The hint was not thrown away, and several surgeons cut circular openings into the cyst to establish a permanent communication with it and the abdominal cavity. But this practice was soon given up, because it was found that the intrusion of ovarian fluid into the serous cavity usually set up a violent and rapidly fatal peritonitis. For such an accident, when followed by inflammation, there is but one remedy--the immediate removal of the cyst by ovariotomy. Desperate as this remedy seems, it has repeatedly been followed by success. The only cyst in which it might be held warrantable to establish a communication with the abdominal cavity is that of a cyst of the parovarium recurring after repeated tappings, and so bound down by adhesions or so covered by the broad ligament as to be irremovable. The fluid it contains is so limpid and bland as not ordinarily to inflame the peritoneum.

OVARIOTOMY.--The term ovariotomy comes from [Greek: ôarion], ovary, and [Greek: tomê], an incision. It is a barbarous compound of Latin and Greek, which is forced into meaning the operation for the extirpation of an ovary on account of some disease of its own structures which causes it to increase in bulk. A fibroid or a sarcomatous degeneration of this organ, as has been shown, will sometimes happen, but cystic degeneration is by far the most common form of disease to which the ovary is liable. When both ovaries are enlarged and removed the operation is called double ovariotomy. The terms ovariotomy and öophorectomy ([Greek: ôophoron] and [Greek: echtemnô], to cut out the ovary) really mean the same thing, the latter word, indeed, being the more appropriate. But by modern usage the former is limited to the operation for the removal of an ovary greatly enlarged by some intrinsic disorder. By öophorectomy is now meant the operation for the removal of both ovaries for the purpose of bringing on the menopause, and thus curing diseases kept up or caused by the functional existence of those organs, while they themselves may or may not be diseased.

Before the eighteenth century the operation of ovariotomy as a radical cure had been suggested by a number of physicians, but had never been put into practice. Later, John Hunter and John Bell both advocated the operation, but neither ventured to perform it. This honor was {314} reserved for Ephraim McDowell, a Virginian practising in Kentucky, who had attended Bell's course of lectures delivered in Edinburgh in 1794, and had imbibed the opinions of his teacher. He returned to Kentucky in 1795, and began at once to practise his profession, but it was not until 1809 that he first met with the opportunity for performing ovariotomy. The operation was successful, his patient having lived thirty-two years longer and having died at the end of her seventy-eighth year. Before his own death, which occurred June 25, 1830, in the fifty-ninth year of his age, McDowell had performed 13 ovariotomies, with 8 recoveries.

In spite of McDowell's success, and in spite of a large and growing percentage of recoveries reported by Atlee, Clay, and Spencer Wells, this operation was condemned so violently by the profession that its advocates were fairly ostracised, and fifteen years have hardly elapsed since it has been put upon as firm a basis as any other capital operation in surgery. "In 1843, Dieffenbach, the boldest of all surgeons then living, wrote that ovariotomy was murder, and that every one who performed it should be put into the dock. Now," writes Nussbaum, "we save lives with it by the hundred, and the omission of its performance in a proper case would in these days be looked upon as culpable negligence."[32]

[Footnote 32: _British Medical Journal_, Oct. 26, 1878, p. 617.]

The most common causes of death after ovariotomy are septicæmia or septic peritonitis, traumatic or frank peritonitis, shock, exhaustion, and hemorrhage; and it is against these foes that the operator must from the first aim all his efforts. In no other operation does the issue depend so largely on the experience of the surgeon. Every ovariotomist finds that his success grows with the number of his cases. Of 1000 successive ovariotomies, Wells lost 34 out of the first group of 100 cases, and but 11 out of the last group of 100. Out of his first 50 ovariotomies, Lawson Tait had 19 deaths.[33] The mortality of his last 313 cases was as low as 4.76 per cent.[34] Keith, who began with a mortality of about 20 per cent., lately had a series of 100 cases with 97 recoveries; 70 of these were successive. Schroeder had in the first 100 of his Berlin cases 17 deaths; in the second 100, 18; and in his third 100, 8 deaths.[35] Of my own first cases, I lost about 1 in every 3. Out of my last 22 cases there was but 1 death, and that occurred in a lady operated on at her home, too distant for me to see her again. In July, 1884, Peruzzi collected statistics up to date of Italian ovariotomists. Out of the first series of 100 cases, they lost 61. In the second 100 there were 36 deaths, but in the third series only 26 died.[36]

[Footnote 33: _Medical Record_, Jan. 3, 1885, No. 2, and _British Medical Journal_, April 15, 1882, p. 544.]

[Footnote 34: _Medical Record_, Jan. 3, 1885, p. 2, and _American Journal of Obstetrics_, July, 1882, p. 547.]

[Footnote 35: _Maryland Medical Journal_, July 1, 1882, p. 110.]

[Footnote 36: _British Medical Journal_, Sept. 16, 1882, p. 528.]

The statistics of the leading ovariotomists up to January, 1883, are as follows:[37]

Cases. Recovered. Died. Mortality,
per cent.
Clay 93 64 29 31.11
Sir Spencer Wells 1088 847 241 22.15
Keith 381 340 41 10.76
Knowsley Thornton 328 293 35 10.67
Lawson Tait 226 199 27 11.94

[Footnote 37: _Medical News_, Jan. 27, 1883, p. 117.]

{315} The statistics of general hospitals are by no means so good. In the Vienna General Hospital during the year 1881 "ovariotomy was performed 64 times, with 38 complete recoveries, 25 deaths, and 1 woman was discharged with marasmus."[38] Taking the profession at large, out of 5153 cases of ovariotomy collected by Baum, there was a mortality of 29.13 per cent.[39] Out of 2023 cases collected by Younkin, the mortality was 27 per cent.[40] By operative skill, by cleanliness, by wise hygienic measures, and probably by the use of antiseptic precautions, the fatality may be said to have been reduced by skilled specialists to about 10 per cent.; which, considering the size of the wound, the importance of the parts involved, and the delicacy of the exposed structures, is a remarkably low average. The average is indeed better than that of amputations. Before 1869, Sir James Y. Simpson stated that the average mortality of amputations of the extremities was 39.1 per cent. In the Glasgow Royal Infirmary the average mortality has been 25.5 per cent.--viz. of thigh cases there were 380 cases, with 113 deaths = 29.7 per cent.; of the leg, 182 cases, with 54 deaths = 29.6 per cent.; of arm cases, 167, with 33 deaths = 19.7 per cent.; of forearm cases, 93, with 12 deaths: mortality = 12.9 per cent.[41]

[Footnote 38: _Medical News_, Dec. 30, 1882, p. 745.]

[Footnote 39: _Agnew's Surgery_, vol. ii. p. 811.]

[Footnote 40: _The New York Medical Record_, Nov. 11, 1882, p. 560.]

[Footnote 41: _Lancet_, Sept., 1882.]

This brings up the question of simple or of aseptic ovariotomy--a very important question and one not yet fully settled. The objections to Listerism are--that it is very troublesome; that it is liable to poison the patient fatally, as well as to injure the health of the operator; that it is useless, indeed merely a surgical craze; and that it is not the carbolic acid which does good, but the cleanliness enforced by this system. But there is no doubt that since the introduction of antiseptic surgery the mortality has been much lessened in every land. For instance, "in Germany, where the success of ovariotomy has not been so good as in other countries, the mortality by means of the antiseptic treatment has been reduced from 90 to 20 per cent."[42] From an analysis of all the cases of ovariotomies performed by American surgeons, "the percentage of recoveries is overwhelmingly in favor of Listerism."[43] During the year 1881 in the Samaritan Hospital two of the surgeons used the carbolated spray of a strength of 1 in 40, and followed out every detail of antiseptic surgery. They had a mortality of 7 per cent. A third surgeon of that institution, after gradually lessening the strength of the spray until water was alone used, finally gave even it up altogether. He, however, for purposes of cleanliness always covered the instruments in the tray with water. The mortality of his operations showed the high rate of 30 per cent. The house committee, a body of laymen, thereupon "expressed a strong opinion against the performance of ovariotomy for the future without full antiseptic precautions."[44]

[Footnote 42: _Agnew's Surgery_, vol. ii. p. 800.]

[Footnote 43: H. C. Bigelow, _American Journal of Obstetrics_, July, 1882, p. 651.]

[Footnote 44: _British Medical Journal_, May 20, 1882, p. 747.]

On the other hand, Tait of Birmingham and Keith of Edinburgh, with a recent mortality each of only 3 per cent., have abandoned the spray. The latter claims now "to get as good results without it, and better results than any one has yet got with it."[45] My own practice is to adhere {316} to the spray and to every detail of antiseptic surgery; and I fully agree with Bigelow that "it would be a grave error to abandon a practice which has achieved brilliant results until something shall be brought forth which shall be as thoroughly protective, and in the use of which there may be no possible dangers. Time alone can demonstrate satisfactorily the relative values of Listerism and of perfect cleanliness without Listerism. The results of a large number of cases in which cleanliness and attention to detail have alone been used are the only criteria upon which we can strike a judicial balance."[46]

[Footnote 45: _Brit. Med. Journ._, May 27, p. 796.]

[Footnote 46: _Am. Journ. of Obstetrics_, July, 1882, p. 651.]

Contraindications for Ovariotomy.--An operation should be declined in far-advanced tuberculosis, in cancer of the ovary or of any other part of the body, in grave structural lesions of any of the vital organs, in ascites if caused by disease of the heart, the liver, or the kidney, in gastric ulcer, or in any serious disease of the alimentary canal. Extensive adhesions should not count as a contraindication, nor should age, since young girls and very old women have been successfully operated on. Albuminuria is often due to the pressure of the tumor on the kidneys, and, unless it existed before the appearance of the tumor or is positively known to be caused by Bright's disease, should not preclude the operation. Extreme debility dependent upon the ovarian disease makes the prognosis grave, but it should not prevent a resort to ovariotomy. I have indeed had several recoveries when the patient was so reduced in strength as to make it a very anxious and difficult task to keep her from dying on the table.

Indications for Ovariotomy.--This operation should not, as a rule, be performed when the cyst has first been discovered, but when it has grown so large as to distend the belly, and when the woman has become thin and her health has begun to fail. The reasons for waiting are--that the woman will have lived longer should the operation turn out to be a fatal one; that, the abdominal wall having become thinner both by being overstretched and by the absorption of fat, the incision will be proportionately shorter and shallower; that, the patient being now less full-blooded, both hemorrhage and inflammation will not be so likely to occur; that the bowels are crowded away from the line of incision; and that the pressure and rubbing to which the peritoneum has been for some time subjected will make it less vulnerable, and therefore less likely to take on inflammatory action. When, however, a woman broods over her condition and is anxious to have the tumor removed, the operation should be performed much earlier, especially if the surgeon be experienced.

Again, when an ovarian cyst is complicated with pregnancy it is best to perform the operation in the first half of the period of gestation; for in the last half the broad ligaments receive a large supply of blood, and all the pelvic vessels become varicose. Pregnancy is indeed no bar to the operation, the prognosis being favorable both to the mother and to the child. Schroeder and Olshausen performed 21 ovariotomies in pregnant women, with only 2 deaths.[47]

[Footnote 47: _Brit. Med. Journ._, Dec., 1880, p. 1027.]

When septic peritonitis sets in; when the contents of the sac become purulent, as they sometimes do either spontaneously or after an unprotected tapping; when the cyst bursts and serious symptoms arise; when torsion of the pedicle occurs or when a free hemorrhage into the sac takes {317} place,--the radical operation should unhesitatingly be performed, and that without any delay.

Preparation of the Patient for the Operation.--The operation having been decided upon, every precaution must be taken to ensure a favorable result. The patient should avoid all exposure to contagious or to zymotic diseases, and she should be put in the very best condition of health possible under the circumstances. If the kidneys be inactive and the urine highly concentrated, depositing mixed urates in abundance, it will be well for the patient to make use of warm baths and to take saline cathartics in quantities sufficient to secure a daily action of the bowels. The alkaline carbonates, largely diluted, will also prove beneficial, and so will also the effervescent citrate of lithia. Sometimes, and especially when anasarca and oedema of the legs occur, it will be advisable to relieve the pressure-congestion of the kidneys by a preliminary tapping. Other organs will also be relieved, and valuable time for the action of medicines is often gained by emptying the cyst. Tonics, iron in the form of Basham's mixture, a generous diet, and fresh air may be needed. A trip to the seashore or to the country will often do much good in preparing a broken-down patient for the operation. If the patient comes from a malarial district, from twenty to thirty grains of quinia should be given during the twenty-four hours for two or three days before the operation, and ten grains a few hours before the time of the operation. If this be not done, a severe explosion of malarial fever after the operation may put the patient's life in jeopardy.

An operation of election should not be undertaken during a monthly period. It should be performed either about ten days before one or about a week after one. The very best time is midway between two fluxes. When, however, through some lesion or some accident, immediate relief is demanded, no regard whatever should be paid to the factor of menstruation. Some surgeons operate, indeed, in any case whether the woman is menstruating or not, and profess to find no difference in the result.[48]

[Footnote 48: T. Savage, _Brit. Med. Journ._, April 14, 1883, p. 712.]

For several days before the operation the bowels should be kept open, and the diet should consist largely of milk, eggs, rice, and of wholesome and easily-digested food. On the day preceding that of the operation the upper portion of the pubic hair should be cut off and the abdomen, if hairy, shaved. In the evening the patient takes a warm soap-bath, and is washed perfectly clean by her nurse, who must be an experienced woman, able to pass the catheter and take the temperature. She then puts on clean clothing and goes to bed, where she stays until the hour fixed upon for the operation. To ensure sleep, I am in the habit of giving at bedtime thirty grains of potassium bromide, combined sometimes with opium. Early next morning a dose of castor oil is administered, and it is much more easily swallowed if disguised in some vehicle and brought to the patient without any previous warning. When oil cannot be taken, I give, at bedtime of the previous evening and in one dose, two compound cathartic and two Lady Webster pills. To avoid ether-vomiting, breakfast should consist merely of one piece of dry toast and a cup of tea, or of a cup of beef-tea or of a goblet of milk, and afterward she must eat nothing more. To calm the nerves another thirty-grain dose of {318} potassium bromide may be given, with or without opium as the case may be, and especially if the woman be at all agitated.

A very good time for operating is from noon to two o'clock in the afternoon, for by that time the oil will have acted and the light breakfast will have been digested. Some surgeons operate as early as nine and ten o'clock in the morning, in which case the cathartic will have to be administered in the afternoon of the previous day. At the hour fixed upon for the operation the woman puts on a flannel sacque, warm stockings, and drawers, and her nurse then passes the catheter.

The bedstead on which the woman is to lie after the operation should have a horse-hair mattress, and should be wide enough to permit her attendants to move her on a draw-sheet from one side of it to the other. I formerly placed my patients on narrow single bedsteads, so that they could be reached and be waited upon equally well from either side; but I found that an unchangeable position on the back soon became intolerably irksome. Next, indeed, to the thirst following the operation, my patients complain mostly of the supine posture which they are compelled to assume.

The room in which the operation is to take place ought to be a separate one, so that the lady can be etherized in her sleeping-room, and may not be unnerved by witnessing the needful preparations. Several days beforehand the carpet of the operating-room should be taken up and the curtains taken down. Every useless piece of furniture should be removed, the closets and bureau-drawers emptied, and the whole room thoroughly cleansed and ventilated. Several hours before the time of the operation this room ought to be heated to a temperature of 75°, and the air disinfected and made moist by a solution of carbolic acid kept boiling in a dish on the stove or over an alcohol lamp. Let me here say that, if possible, this operation should not be performed within the walls of a crowded general hospital nor in unhealthy localities, but, as statistics well show, in private houses or, far preferably, in small special hospitals.

Articles Needed for the Operation.--The following articles should be provided by some member of the patient's family. Following the example of the late Washington L. Atlee, I have a printed list of them, which is sent to the family physician some days before the operation:

One yard of rubber plaster; two rolls of raw cotton, made aseptic by being baked in the range-oven just before the operation; two yards and a half of fine white flannel, for two binders; six one-grain rectal suppositories of the watery extract of opium; two pounds of the best ether; two gallons of a 5 per cent. solution of the best carbolic acid, made at least two days beforehand; four ounces of Monsel's solution of iron; twelve ounces of undiluted alcohol for the spray-producer; some old whiskey, with cup, spoon, and sugar; a nail-brush, basin, and soap; a pin-cushion, with large pins; two kitchen tables, or two dressing-tables; one small stand for the spray-producer; one small table for the basins and sponges; one chair without a back for a bucket of hot water; two new tin basins and one tin cup; a new bucket and a jug of hot water; a kettle of boiling water, ready on the range; a small tub and an empty bucket; six bottles filled with hot water and tightly corked; an empty wine-bottle for the aspirator; a rubber ice-cap or two pig's bladders for holding ice; a rubber-cloth one yard and a quarter square, with an oval hole in the centre six inches wide and eight long; one kitchen apron for the operator; one {319} clean blanket for the patient's lower extremities; two large platters or two meat-dishes, to be used as trays for the instruments;[49] clean towels, clean sheets, clean blankets, clean comfortables, and clean pillows.

[Footnote 49: These platters are usually too shallow to hold a solution of carbolic acid deep enough to cover the bulkier instruments. It would therefore be well to have a tin tray made especially for the purpose, measuring nineteen inches long, twelve wide, and three deep; or a nest of smaller trays can be carried in the operator's bag.]

Instruments.--In simple cases very few instruments are needed; but as one never knows beforehand what complications may be met with, it is best to be always prepared for every emergency. One must therefore have on hand every instrument likely to be wanted in the most formidable operation. The following list comprises all the instruments and other articles that I carry with me in my operating-bag, but it will not suit every surgeon, who will after a few operations choose his own favorite instruments: