OVARIAN TAPPING FOLLOWED BY A CURE. By E. H. M. SELL, A.M., M.D., OF NEW YORK. THE subject, whose history I am about to present to this Section, is Mrs. Mary Z., who was born in Würtenberg, Germany, Feb. 16, 1849. As a child, she passed through the several diseases common to childhood. At eight she was run over by a butcher's wagon. At the age of twelve she suffered from chlorosis. She commenced to menstruate when about thirteen, and continued regular for six months, when, on getting off from an omnibus, she fell, and was both injured and frightened, after which she suffered from suppression of the menses for from six to eight months. She was married June 10, 1866, being then seventeen years old, and is the mother of five children. The eldest is eight, and the youngest two years and five months. The first symptoms of ill health presented themselves during the last two months of her last pregnancy. These were pain and tenderness in her left groin, none in the pubic region, and pain in her left side during coitus. From her increasing size and general symptoms she considered herself pregnant. About the middle of February, 1874, she was seized with pain and flooding, which a midwife and a physician, who were called, diagnosed "threatened abortion," and ordered medicine to "hurry on expulsive pains," doubtless a preparation of ergot. At this juncture my friend, Dr. E. J. M., was called to see the case, and diagnosed a fibroid tumor of the uterus and pneumonic solidification of the right upper lobe. The doctor then called me in consultation. On visiting the patient, I found her residing in a damp basement, No. 116 Eldridge Street, where she sold kindling wood. Her general appearance was cadaverous, complexion very sallow, and emaciation extreme, progressing from the date of her last pregnancy. The temperature of her body was high, and perspiration copious. Thickness of abdominal parietes not considerable, no linea albicantes were visible, nor dilated veins. A bimanual examination revealed a tumor, which had considerable mobility, speaking against adhesions, extending a little above the umbilicus. Fluctuation not very perceptible, so slight, indeed, that Dr. M. did not make out and corroborate my diagnosis till five weeks later. There was no crepitus, and scarcely any tenderness on pressure, save in the left inguinal region. Percussion sounds were dull, except in the lumbar regions, where they were tympanitic. Auscultation of the abdomen gave negative results. The uterus was normally situated, movable, and the vagina also normal. She had leucorrhoeal discharges, and has had them since her first confinement. She had neither dysuria nor incontinence, but complained of a smarting sensation on passing water. Urine very high in color, and deposited a sediment on standing. Her tongue was very much coated. She had no appetite; great thirst and considerable flatulence, constipation and diarrhoea alternating. There was great insomnia, due to dyspnoea. Her mental condition was disturbed and flighty, but not hysterical. Previous to her sickness she had suffered from facial neuralgia, of which she was entirely relieved. Her breathing was very much compromised. She had a strong cough, with some expectoration. Rested best on her left side; and also had an idea that lying on her affected side might improve her condition. Had a frequent pulse, and considerable palpitation of the heart. Hereditary Influence.-Her father died young, when patient was yet a child. Her mother had the dropsy and some uterine trouble when thirty years old, but now enjoys health. She has no brothers, sisters, nor any near relatives. Has lived in New York since she came to America. Her mode of life has always been active, latterly with household duties, and assisting her husband. No moral causes were traceable, but the patient thought that the dampness of her abode had considerable to do with her sickness. There was no vaginal fulness, no bearing down of uterus, save for two or three weeks after each confinement. Had no special pressure on the bladder, but could never retain her urine very long. The patient complained of pain in her left groin, numbness of her feet, and great weakness of her legs, but no nausea except on taking medicine. Up to this time she increased in size but slowly, yet her early symptoms were rapidly aggravated, and still she had rest from time to time. Several times she had had, when pregnant, tympanites, and frequent febrile attacks, but apparently no cystic inflammation. She had no signs of peritonitis or ascites, nor any discharges pointing to a spontaneous rupture of the cyst either through the uterus, vagina, bladder, bowels, or abdominal wall. Diagnosis. A simple unilocular ovarian cyst on the left side. Prognosis. As the patient was apparently fast declining from a pulmonary and throat affection, suffering greatly from dyspnoea and high fever, our prognosis in the case could but be unfavorable; hence we recommended tapping the cyst in preference to ovariotomy, enjoining a strong tonic treatment, remarking that, should she survive and the cyst refill, tapping might be repeated several times if necessary, and, should her health at any time justify an operation, then perform ovariotomy. The tonic treatment was adopted, but, our diagnosis not being accepted, naturally excluded. tapping for the time being. We remarked on parting, that, whenever our diagnosis was accepted and our presence requested, we would be ready to tap. This time came, but not till five weeks later. On March 28, 1874, Dr. M. called upon us, saying that he had accepted our diagnosis, and requested us to revisit the patient with him, being prepared to tap if we thought proper. We found the patient, now living with her mother at No. 126 1st Avenue, very much larger than five weeks previous; the tumor pressing out the sternum and floating ribs; the dyspnoea, being much greater, necessitating almost an upright position of the patient. We were requested by her and her mother to do what we thought best. Hence, after dividing the skin, we tapped, using the valuable trocar of Mr. Charles Thompson, of Westerham. We obtained fourteen pints of a greenish viscid fluid, which, being microscopically examined, revealed, besides several of the contents usually found in a unilocular ovarian cyst, a large amount of pus. The tapping at once relieved the dyspnoea and insomnia. The tonic treatment was continued, and the patient's health rapidly improved. Nevertheless, the cyst rapidly refilled, and in three weeks thereafter a tumor of the size of an orange was perceived at the point of tapping, which spontaneously broke and discharged large quantities of the same kind of fluid. Thus the cyst refilled and discharged itself every two or three weeks some eight or ten times, flowing generally about two days, the quantity gradually decreasing till it finally ceased altogether, leaving only a small scar at the place of the puncture, three fingers' breadth below the umbilicus, in the linea alba. On visiting the patient, April 2, 1875, more than a year after the operation, living at No. 343 East Ninth Street, we found her enjoying perfect health, without any enlargement, and able, besides doing her own housework, to go out washing and house-cleaning. Remarks. We consider this not a unique but a very rare case. Mr. Spencer Wells teaches that true ovarian single cysts (excessive growth of one Graafian follicle) are almost certain to fill again; while the extra-ovarian cysts (dilatation and growth of part of the remnants of the Wolffian body, or parovarium) are often radically cured by a single tapping. The case under consideration was plainly a true ovarian cyst, as shown by its contents, which were albuminous, and contained: 1. Fatty granules varying in size. 2. Globular aggregations of various sizes. 3. A large quantity of small circular corpuscles, containing a varying number of fine black molecules, like the exudative cells of Henle (exsudats' zellen). 4. Cholesterine crystals. While the contents of parovarian cysts, according to Mr. Wells, consist of little more than pure water, with scarcely any albumen, or only a little albuminate of soda. Again, this cyst did refill itself several times, but, as it discharged itself spontaneously, we are justified in saying that a cure followed a single tapping, showing us the importance of trusting to tapping, at least in some cases, of true ovarian single cysts, and especially where the physical conditions of the patient contraindicate ovariotomy. |