OVARIAN DISEASE COMPLICATED BY PREGNANCY.

BY DR. T. B. HARVEY.

It would seem at first thought that the terms used at the head of this paper should be reversed, as pregnancy is physiological, and ovarian tumors pathological, and it is so treated by some recent obstetric authors; but from the gynecological standpoint, and by some obstetric authorities the above relation of the terms is observed. To those who have not had their attention called to the subject it may appear not to be worthy of much consideration from the general practitioner, as he would refer such cases to those who are especially engaged in ovariotomy. As the subject has never before been presented to this Society, and is certainly one in which the general practitioner is first and most intimately connected, it is thought by the writer to be eminently a proper one for consideration. Before ovariotomy became an accepted operation the authorities on obstetrics could not view the subject from the standpoint of operative interference, and as a consequence confined their treatment to palliative measures, such as tapping during gestation, and possibly in parturition, and in the latter condition to preventing obstruction to labor, or to embryulcia.

Since ovariotomy has become the most successful of all major operations, we are justified in looking at the subject from the side of radical means. My attention has been called to it more particularly by my experience in several cases, which it may be of some interest to relate in this connection. Mrs. D., æt. 30, had an abdominal tumor thought to be ovarian, but which she had determined not to have removed. She had been tapped annually for three years. In 1864, I was called to see her and requested to tap, as she would

have nothing else done. I did so, removing three and a half gallons of clear fluid. In a few months she became pregnant, and I was consulted by the parties, including the family physician, as to the propriety of early abortion. Having but little authority to govern me at that time I decided, in oppositon to all concerned, that we should wait and trust to developments, impressed with the opinion that if gestation was so interfered with by the tumor that spontaneous abortion occurred it would be safer than by artificial means, and that it was possible that the gravid uterus might prevent the rapid filling of the cyst. The latter proposition proved correct, as gestation was not interfered with, and at full term she was delivered of a living, healthy boy, weighing thirteen pounds, and the tumor did not fill again until the next year.

Case 2. Mrs. C., æt. 30, multipara, was known to have a tumor for several months, supposed to be ovarian, of the size of a child's head. Pregnancy took place and the tumor and gravid uterus were watched in their development, the tumor above the uterus, until after the sixth month, when the whole contents of the abdominal cavity appeared to be blended. Gestation was not disturbed, and delivery at term followed with living child. It was then observed that the tumor had adhered to the epigastric region, and as retraction of the uterus took place the tumor was drawn in an oblong shape, between the epigastric and pelvic regions. From the constant traction between these points, inflammation at the site of adhesion in the epigastrium had taken place and suppuration followed. Perforation of the abdominal wall, including the cyst wall, with three openings in the skin, from which pus gushed at every effort at coughing was the result. When I saw the patient, about one year after parturition, she was greatly emaciated, and with septic fever of 103. I removed by aspiration a gallon of offensive pus from the tumor, and gave the patient the option of an effort to save her by the one only chance, that of removing the tumor. She elected it, and it was found that there were no adhesions on the lower third, and a small pedicle made the connection with the right side. There were adhesions in the upper two-thirds, extending from below the umbilicus to the stomach, transverse colon and liver. The cyst had again filled with offensive pus. The patient did well for five days, but died from some unknown cause other

than that she was permitted on that day to get out of bed, when a very large liquid stool took place. This patient should have been operated on as soon as the tumor was found, or very soon afterward, and the probability is that she would have recovered.

Case 3. Mrs. G., æt. 27, was delivered on the 19th of August, 1886, of her second child by a midwife, who stated that no pains would come so long as the patient occupied the dorsal position, but were regular and effective on the right side, in which positon she was delivered of a boy, weighing ten pounds net, but there was apparently no subsidence of the abdominal enlargement, and I was called on the evening of the same day. I found the abdominal enlargement very great, with very distinct fluctuation, and the patient without symptoms of internal hemorrhage. The uterus, examined per vagina, was found contracted, and a history of abdominal enlargement prior to the pregnancy justified a diagnosis of ovarian tumor. This patient was treated by tonics, prominent among which were the tinct. chl. iron and quinine, for twenty-seven days, as she had decided malarial symptoms, when the puerperal condition was so much improved that it was deemed best to remove the tumor without further waiting, as it was certainly enlarging rapidly. Ovariotomy was performed on the twenty-seventh day, with the assistance of Drs. Guido Bell, F. C. Ferguson, Frank Morrison, Orange Pfaff and L. M. Rowe.

Slight adhesions were found over the entire anterior surface. The main portion of the tumor consisted of a large cyst with very thin walls, with a collection of small cysts in the upper part, the size of the foetal head constituting a multilocular tumor, the weight of which was estimated to be fifty-five pounds. The patient made a rapid recovery, uninterrupted except by the existence of gonorrhoea, which her husband admitted to have communicated to her. This patient has nursed her child from the first, and is now in good health with the exception of a discharge as from an ulceration at the umbilicus, which has no cause as far as I know, except that the ring was so stretched during gestation that rupture took place.

The dangers of the expectant plan may be summed up in a few words:

1. Rupture of cyst walls, with death by shock or peritonitis.

2. Twisting of the pedicle and gangrene of tumor, with death by septicemia.

3. Uræmic intoxication from pressure on the kidneys.

4. New adhesions to parts in which they are not often found in uncomplicated cases, as stomach, colon, liver and abdominal walls high up. The last cause is not generally considered by authors, but is mentioned by Tait and Emmet, and the first, that of rupture of the cyst walls, is generally only mentioned as obtaining during gestation or parturition, whereas this danger often presents itself after delivery, on account of a rapidly filling, thin-walled cyst, to say nothing of the damage to other organs by the great distention, and particularly paralysis of the diaphraghm. The dangers of a palliating treatment by tapping are, 1st, That such procedure is liable to produce peritonitis and adhesions. 2d, That the fluid is largely albuminous, and if frequently withdrawn exhausts the patient, and if successful in carrying her to full term, leaves her with an ovarian tumor to be subsequently removed, which may cause great difficulty in delivery, thus endangering the life of mother and child, and, moreover, tapping is not applicable to polycystic tumors.

The arguments in favor of ovariotomy as soon as the tumor is discovered are:

1. That the smaller the tumor the greater the success, whether pregnancy exists or not.

2. From the reported successful cases it appears that pregnancy does not very greatly increase the danger of ovariotomy in the early months, and gestation as a rule is not disturbed. But if the case is only diagnosticated in the latter months of pregnancy when the tumor is of considerable size, ovariotomy would give the best prospect for recovery. There is less danger of rapid filling and rupture of the cyst before than after parturition, and the pregnant condition is as favorable as the puerperal for at least a month after parturition. One cause for the change in opinion of obstetricians, and gynecologists, and the pronounced views of some in favor of ovariotomy, is found in the greater success of the operation at the present compared with a quarter of a century ago. Another cause for the change is the objection to tapping on account of present danger

and future results. A third cause is that the statistics of ovariotomy during pregnancy show nearly as good results as in the absence of this complication, and more lives are saved to mother and child than by the expectant or palliative treatment.

It appears to be a harsh measure to recommend when a considerable number of cases are recorded where no interference or only tapping conducted them to a favorable termination. But it must be borne in mind that the presence of an ovarian tumor in any condition is a lethal lesion sooner or later if not removed, and in large cysts, and those complicating pregnancy, great mischief is done to other organs, and often death results when timely removal would have saved life and preserved health.

I have not found it possible to collect statistics at present of this operation, nor of the deaths resulting from an opposite course, nor of recoveries from expectancy or palliation, but certainly the results obtained by the most successful operators of the present are such as to impress one with its propriety.

It will better present the current literature of the subject if a few quotations from some of the many authorities who have mentioned it are given. In so doing it will be seen that the question has been pretty thoroughly discussed, but that a uniformity of opinion was not reached until within the last decade, or latter part of it, if we can say that even now such uniformity exists.

Wells, in discussing this subject says:

"Ovarian tumors may not only be mistaken for pregnancy when they exist independently, but they are often complicated by its occurrence even in advanced stages of their growth. And though the diagnosis of this condition is generally to be made out of the course of ordinary treatment, yet the complication may be revealed only at the time of the operation. Out of these circumstances several very important practical questions arise.

"It may be asked, in the first place, whether in such a case it would be necessary to interfere at all, under the assumption that pregnancy and ovarian disease might go on together, and serious trouble arise only in a small percentage of cases. The early induction of premature labor has also been advocated, on the grounds that rupture of the cyst, or gangrene from rotation of the pedicle, were apt to occur under the pressure of the enlarging uterus, while relief was often found in the advent of spontaneous premature labor.