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.]