OVARIOTOMY DURING PREGNANCY—ACASE WITH REMARKS.*

WILLIAM GARDNER, M.D.,

Professor of Gynaecology, McGill University ; Gynaecolo-gist to the Montreal General Hospital.

On the 10th November, 1884, by the advice ofmy friend, Dr. Dug-dale, of this city, I was con-sulted in the case of a lady, set. 37, the subject ofan abdominal tumor. She had been married 18or 20 years and was the mother of two children,one a grown-up daughter, born a year after mar-

riage , the other 11 years of age. A few monthsafter the birth of the last child she began to sufferfrom cough, haemoptysis, pain in the chest, dysp-noea, emaciation, and all the other evidences, gen-eral and local, of phthisis. The physical signsexisted mainly in the right lung, in the apex ofwhich a cavity was diagnosed. So serious werethe symptoms at one time, that it was thought byher medical advisers that she had but a few monthsto live. She however rallied, and although neverlong free from cough and expectoration, her gen-eral condition became much better and she had for

from Canada Lancet, February, 1887.

several years lived in tolerable comfort. To thisresult the preparation known as Hydroleine hadseemed to contribute very much. Between threeand four years previous to my seeing the lady, atumor, diagnosed as ovarian, had developed, andwhenI saw her the abdomen was enlarged therebyequal to pregnancy of six months. All the evi-dences of cystic ovarian tumor were present, butas it had grown none for a year or two, was notpainful, did not seem to bo markedly affecting hergeneral health, and as a portion of the tumor oc-cupied the pelvis where it might be adherent,seriously complicating ovariotomy in a delicatewoman, I advised non-interference until some in-dication for prompt action arose. My advice wasfollowed. I did not again see her till early inMay, 1886. I then learnt that the lung symp-toms had been alternately somewhat active andquiet, the tumor remaining stationary till March,1886, when it began rapidly to increase in size ;

menstruation, which had hitherto been quite regu-lar, ceased on 16th February, after a natural flow.There had been nausea and some vomiting. Thelarge increase of the tumor had produced muchdyspnoea and pain in the right side of the chest.On some nights the patient had been unable to lie,from difficult breathing. I found her emaciated

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and slightly livid from impeded breathing. Thebreast signs were doubtful, but on examina-tion the vagina was purple in color, and both itand the cervix were markedly softened. Enlarge-ment of the uterine body, commensurate with theprobable durationof pregnancy, was tolerably wellmade out. That part of the tumor which occupiedthe pelvis, at the examination eighteen monthspreviously, had disappeared upwards. The patientbelieved that she was pregnant, and so did herphysician. 1 could only agree. She was watchedfor a fortnight or more. Her sufferings decidedlyincreased, and it became apparent that promptaction was necessary. Both patient and her hus-band (a non-practising physician), urgently desir-ing the operation. After gentle purgation anddieting for two days, on the 29th May the operationof ovariotomy was done at the home of the lady,Drs. Roddick and Bell assisting. Ether was theanaesthetic used, not however without some mis-giving as to its possible effect on the lung condi-tions. The operation was simple and easy a

unilocular cyst of the right ovary, with favorablepedicle and no adhesions. On getting into thebelly, it was interesting to note the contrast be-tween the dark red fundus of the womb, as it laybehind the pubes, with the pearl-colored tumorabove it.

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The after-course of the case was easy and unin-terrupted to recovery; no sickness and very little-pain ; the cough, necessary to get up the expecto-ration, being the only distressing symptom. Thewound healed without a fraction of a drop of pus,either at the line of union or stitch-holes. Shewas kept in bed four weeks to allow of the cicatrixbecoming firm under the strain of the developinguterus. After three months’ absence in Europe,I called on her in October and found pregnancyadvancing, but the enlarging uterus causing con-

siderable distress in breathing. She was confinedby her physician at full term on the 26 th Novem-ber, three days less than six months after thedate of operation. Labor terminated naturallyafter six hours. It was followed by alarminghemorrhage, which led to fainting and syncope.It was controlled by ice. The child, a fine healthyboy, weighed nearly ten pounds. She made anexcellent recovery, suffering from nothing of anymoment, except weakness from loss of blood.

The complication of ovarian tumor with preg-nancy is one which must always justify muchanxiety. This is greatly increased if, as in thecase just related, there be a further complicationwith grave lung disease. The effect of pregnancyon a previously existing ovarian tumor is as a rule

to stimulate it to rapid growth, with the obviousresult of serious encroachment on adjacent viscera.The condition of the lung in this case greatly in-creased the patient’s sufferings. The remarkablefact that this was first pregnancy afternearly twelve years, must be noted. Not-withstanding the fact that there are now onrecord a number of cases of successful ovariot-omy during pregnancy, obstetrical authorities andthe general profession are not in perfect accord asto the proper course to pursue in these trying cir-cumstances. It is quite true that women have inrare instances borne several children safely at fullterm, while suffering from ovarian tumor, butthese are few when compared with the many fatalcases of premature and full time labor to be foundrecorded in the annals of the subject. Duringlabor the tumor may burst, or its pedicle be twisted,or it may suffer such injury from pressure that itsuppurates, with almost invariably fatal results ineach case. The only thing to give the patient achance under these conditions, must be immediateoperation to remove the tumor, under very unfa-vorable circumstances. When during labor thetumor suffers no injury, the puerperium is ofteninfluenced very unfavorably. If the patient sur-vive, the tumor must be dealt with sooner or later

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to save her life. The size of the tumor does notmuch influence the result. A large tumor whichhas of course become abdominal, together with thegravid uterus produces dangerous pressure on ad-jacent viscera of abdomen and thorax ; while onthe other hand a small tumor, probably occupyingthe pelvis, is more liable to such injury as shall leadto rupture or suppuration with consequent peri-tonitis.

Isolated cases of fatal, supposed puerperal sep-ticaemia or inflammation from this cause are cer-tainly much more common than is generally sup-posed. A paper by Dr. Grigg on some cases ofthis kind, read before the British GynaecologicalSociety last June, is of great interest in re-

ference to this subject. It was a record offive fatal cases, the whole mortality at theQueen Charlotte’s Lying-in Hospital, London,during nine months. A careful autopsy was

made in each case, and the result showed that infour, diseased conditions of the uterine appendageswere present and more than enough to cause death,and which, had they not been fully investigated,would have been put down in the category ofpuerperal septicaemia. Two of the four weresmall ovarian cysts ; one of them suppurating. Athird was abscess of the left ovary and pyosalpinx.

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The alternative to ovariotomy for relief from a

large ovarian tumor is tapping, and it is still urgedby the more conservative of the profession. Itcan do good only in unilocular cyst. It is attendedby many dangers. It is not a radical cure andmay be only temporary in its results, for thecyst may rapidly refill, and in any case sooneror later the radical ovariotomy must be done.

The induction of abortion or premature laborcannot be recommended as it has been shownas the result of experience, to be by no meansfree from danger to the mother, while thechild must usually be sacrificed, and yet, as a

result of conversation with my professional bro-thers, it seems to be the course which is mostlikely to suggest itself. I believe I am justi-fied in saying that, in the complication of ovariantumor with pregnancy, when the case is diagnosedbefore labor begins (for which, however, there isnot always the opportunity), the rule is tobe laid down, to promptly remove the tumor, andthe earlier this is done, the better are the chancesfor both mother and child. It may be furtheradded that serious organic lung disease does not ofnecessity complicate the operation or render etheras the amesthetic more dangerous.