I~OTES ON A LAPAROTOMY FOR A RUPTURED OVARIA!g OYSTOMA.

BY ALFRED SMITH, F.R.C.S. ; Professor of Midwifery in the Catholic University School of Medicine;

Gynmcologist to St. Vincent's Hospital.

[Read in the Section of Obstetrics, February 7, 190"2.]

Ov~_~r cysts, we lmow, may spontaneously rupture into the peritoneal cavity or into some neighbouring organ. When they rup tm~ into the peritoneal cavity the effect on the patient of course depends on the character of such a cyst and of its contents. A malignant cyst may rupture and be followed by dissemination of new growth in the abdomen. An innocent ovarian cyst generally produces but trifling symptoms. Each rupture is accompanied by sudden pa'm, profuse diuresis, lasting, it may be, for a couple of days, carries off the excess of fluid, and the tumour, altered in shape, gradually refills. There may be a true s acute rupture of an ~nnocent ovarian cyst followed by fatal hsemolThage and peritonitis. Death even may be so rapid that it seems due to septic intoxication from absorption of the fluid. In such cases there is generally a previous twisting of the pedicle followed by thrombosis of vessels, intracystic hssmorrhage and necrosis.

The following case will, I hope, be of interest to members of this Section as showing what grave symptoms and profound shock may follow spontaneous rupture of a common multi- locul~r glandular cystoma : - -

CAS~..--Dr. Leo Keegan, House Physician to St. Vincent's Hospital, reports that he was called to see a patient on January 19th, about noon. She had been seized with a violent and sudden pain which she referred to the umbilical region. He found her in a collapsed condition ; the abdomen was distended, the respiration was

a Doran. Tra~q. Path. Soc. Vol. XXXI., p. 180.

224 Laparotomy for a Ruptured Ovariau Cystoma.

rapid' pulse 110, temperature 96 ~ F., and she was bathed in a cold sweat. On careful examination he diagnosed an ovarian cyst, and concluded that it was a case of rupture and sent for me. While waiting my arrival he administered restoratives and kept a careful record of pulse and temperature. The patient recovered some- what from the initial shock, but about 5 30 o'clock her temperature suddenly w e n t u p to 103"8 ~ F. and pulse 140 ; her condition became grave. On my arrival I determined to operate at once, and had the patient conveyed to the gynecological theatre, St. u Hospital. I opened the abdomen, assisted by Mr. Paget Butler and Dr. Leo Keegan. I found a large transverse rent in the capsule and the peritoneal cavity filled with gelatinous cyst contents. There were numerous omental adhesions, and their separation was greatly hampered by the gluey fluid with which they were covered. Having separated the adhesions and tied the pediele, I douched out with hot saline to remove as much of cyst fluid as possible without sponging. It was gratifying to find how the hot saline, temperature 101 ~ F., seemed to liquefy the gelatinous fluid and facilitate its removal.

Condition of Patient after Operation.--A stimulating saline enema was given to the patient after operation. She spent a restless night from constant retching and thirst. In the morning the temperature fell to 100 ~ F., pulse 132. During the day the pulse-rate increased to 140, temperature 100"6 ~ The abdomen became distended, and the eolour of the vomit a dark green. It came up in mouthfuls without effort. Altogether the condition of the patient was very grave. I ordered the stomach to be washed out with a weak boric solution. This gave temporary relief, and patient spent a somewhat better night. On seeing the patient on the morning of the 21st, nurse reported a return of the vomiting and much distension. I again ordered the stomach r be washed out and a large turpentine enema to be given, with good result. The pulse-rate and temperature fell, and the patient's recovery was uninterrupted.

The points of special interest are : - - 1. The cause of the spontaneous ruptm-e. 2. The explanation of the toxic syrup,)ms before operation. 3. The t reatment of the persistent vomiting after operation.

The Cause of the Spontaneous Ttupture.~As a rule with

By DR. ALFaF~D S~,~rm 225

large cysts their rupture is due either to traumatism, a blow upon the abdomen, a fall, the strain caused by vomiting, or to fatty degeneration caused by thrombosis. In my case the patient was lying in bed when the rupture occurred. She was a young woman, aged twenty-six, she was married one year and seven months, and she gave birth to a full term child eight months ago. She had a normal labour and puer- perium. She noticed nothing unusual in her condition until three months after her con~nement; she was then disturbed by a lump "falling about" from side to side as she altered her position in the bed. Having consulted her doctor in November last he sent her up to Dublin for treatment. She was retrained home, she says, as pregnant. The abdomen increased so much in size that she was sent up to me. I had not seen the patient until after the rupture occurred, but I am informed she was able to walk without distress or incon- venience. I am inclined to believe the rupture was due to tension from within acting on a fatty degenerated patch in the th~n wall of the cyst. This accident, according to Pozzi a occurs most frequently in the case of gelatinous cysts such as was found in this case.

The Explanati(m of the Toxic Symptoms before Operation.- The fiLfid in glandular cysts is generally of fairly high specific gravity--1010 to 1030. I t contains much albumin and muoin, and broken-down cellular elements. The albumins are complicated, consisting of para-albumin and recta-albumin, the former being closely allied to mucin, and the latter is designated by Hammarstein b as pseudo-mucin and by Pfan- nensteil ~ as glyco-proteid. Now this pseudo-mucin is very abundant in cysts containing tough, sticky fluid; it is a secretion, not a degeneration, and it does not occur in par- ovarian cysts. As toxic symptoms do not follow the rupture

Pozzi. Meal. Surg. Gynmeology. Vol. H., p. 181. b Hammarstein. Zeits. f. Phys. Chem. 1882. �9 Pfannensteil. Arch. f. Gyn. u XXXVII., p. 407.

P

226 Lapa~vtomy for a t~uptu.red Ovaxia~ Cys~oma.

of ordinary parovarian cysts, it might be that the absorption of large quantities of this glyco-proteid would pal~ally explain the tox~emia. Added to this the many broken<lown cellular elements of various kinds which fon~n part of the fluid would fm-nish ferments, the effect of which thrown into the ci~ culation would give rise to toxic symptoms.

The Trea~men~ of Persisten~ Vomi~iq~g.--This case I think illustrates the great advantage of washing out the stomach for the relief of persistent vomiting after operation. I do not now advocate the exhibition of gastric sedatives. Ha~4ng washed out the stomach if the patient is much distended, a large stimulating turpentine enema is given to reestablish if possible the normal peristaltic action. The specimen presents no point of interest; it is an ordinary multilocular glandular ovarian eystoma?

DR. KIUD asked had any food been taken by the mouth before the operation, and, if so, what was its character ~.

DR: W. J. SMYL~ stated that he found rupture of ovarian cysts to be caused by tapping, particularly if the operation had been repeated. In one case, after laparotomy had been performed, the contents of the cystoma had escaped into the peritoneal cavity, and so much time was occupied by wiping the matter from the coils of intestines that the patient collapsed. He certainly pre- ferred Dr. Smith's process of flushing out the cavity. Massage was also to be credited with causing the rupture of such tumours. He had seen the daily practice of massage diminish an ovarian cystoma to the vanishing point--the turnout had been ruptured and its contents rubbed out of the sac. Even gentle palpation has caused rupture. In the Adelaide Hospital, wbi[qt very care- fully palpating a tumour it burst, and at once he performed laparotomy. He found a malignant cystic tumour, which he removed, and the patient recovered from the operation well, but some months after the disease recurred.

In reply, DR. ALFRED SMITH stated that he looks on washing out the peritoneum as the rational method. Vomiting commenced from the moment of consciousness from the etherisation.

a Roberts. Outlines Gyn~ecological Path. P. 207,