Septic Infection of OvarianCystoma

nvCHARLES GREENE CUMBTON,

H.M H., M I).

AHHlHtant I’rofiwMorofSurgtcul Pathology,Tuft* Oollom Medical School, lioNton :

Fellow of tlio American AeNoclallon of< tbrttetriciiuiH mill < iyiiecologlHlN ; C»rresponding Member of the AMtociutionof «i<-iiit.> I rmury Surgeon* of Prance,of the OlMtetricnl nod GynecologicalSociety of i’nrlN, of the PathologicalSociety of liruerelH, etc.

■ifmxrtu nMTint American Journal op iirmtethice

Vol XXXViII. N». 4, |(VH

NEWYORKWILLIAM WOOD A COMPART, PUMI.IHHENH

I Him

SEPTIC INFECTION OF OVARIAN CYSTOMA.'

The question of suppuration arising in either simple or der-moid cysts of tho ovary is one that has only been talked of bygynecologists within tho last liftoen years, although long be-fore that time a few cases are to be found scattered throughoutmedical literature, and it appeared to tho writer that a generalconsideration of this rather important question of al>dominalsurgery and gynecological pathology might not be out of placeat this time.

The advance made in abdominal surgery and bacteriologyhas at tho present time put the question of suppuration of ova-rian cysts quite well forward, and in tho recent and excellenttext books on gynecology by Keating, Penrose, Webster, Gar-rigues, and other writers, all mention this complication, but donot give it tho prominence to which wo think it is entitled.

Pathologically, ovarian cystoma may be divided into epithe-lial and dermoid cysts. If these cysts are situated in the ovarythey are called ovarian, while if they are included in the parova-rium they are termed parovarian cysts, and according to thecase they either have or not a pedicle. If their cavity is com-posed of a single pocket they are termed unilocular, but, onthe contrary, when tho walls are adherent and the cavity com-posed of a number of small pockets they are termed multi-locular cysts.

The wall of an epithelial cyst is made up of two hners —anexternal layer which is extremely dense and conqKJsed offibrous tissue which is poor in cellular elements, and is linedby a cubic epithelium which differs from the flat endotheliumof the peritoneum. The internal layer of the wall is well pro-vided in cellular elements and blood vessels, and is lined by anepithelial layer comprising a few elastic fibres. Between these*two layers a third one is to be found, to which the name ofcellulo-vascular layer has been given. The contents of those

1 Read before the American Associatiqnof QligJgtcifliaOS and Gynecolo-gists, at Pittaburg, Pa., September ‘JO- !‘2,

2 CUMSTOX: SKI'TIC INFKCTION

cysts are liquid and usually a light yellow or slightly greenishin color, but in certain examples the contents may be a red-dish-brown or chocolate color. The consistence of the liquidvaries from that of serum to the thickness of gelatin.

The wall of a dermoid cyst is a structure very similar to thatof the dermis of the skin, and contains unstriped muscle fibres,blood vessels, nervous elements, papilla), sebaceous glands,and hair follicles. Their contents are made up of sebum mixedwith epidermic products.

Now, if we admit that these cysts, either of the epithelial ordermoid type, undergo an inflammatory process, the resultwill bo a suppuration of the cysts. Pus may exist in a largeor small quantity, according to the size of the cyst and accord-ing to whether one cavity or only a few of the smaller onescontain this pathological product. Sometimes it is greenish,at others yellow; sometimes it is dirty, with only a slight odor,while in other cases it has been found of a creamy consistencewith a very strong odor. When submitted to bacteriologicalexaminations the pus has been found either free from micro-organisms, in which case it was sterile, or, on the other hand,micro-organisms were present.

Sterile pus has been the least frequently met with in cases ofsuppurating ovarian cysts. In one case reported by Fraisseand Legrain in 1892 an ovariotomy was performed and fifteenlitres of pus withdrawn, and neither by staining nor by cul-ture on various media, nor by inoculation of guinea-pigs underthe skin or intraperitonoally, could the presence of any bacteriabe demonstrated.

Pus containing bacteria is by far the most frequent, thestreptococcus and all the staphylococci being found. Hmninreports a case which ho observed, in which by culture he dem-onstrated the presence of streptococcus. Schiperovitsch,Worth, and very recently Keen, of Philadelphia, in his impor-tant monograph on the “ Surgical Complications and Sequelsof Typhoid Fever,” have all contributed cases in which Eberth'sbacillus was found in the pus. Madlener has reported one caseof suppurating cyst of the ovary in which Koch’s bacillus wasfound, while Schauta rejKjrts one in which diplococcus ofpneumonia was present in the pus.

In 1893 Bumin made cultures from the pus taken from anovarian cyst, and found organisms which were apparently thebacterium coli and staphylococcus; and Mangold in 1896 de-scribes a case in which ho also was able to demonstrate thepresence of a staphylococcus, bacterium coli, and an organism

3OF OVARIAN CYSTOMA.

which resembled the gonococcus. In most oases the walls ofthe cyst will be found to have undergone a certain number ofchanges macroscopically. The walls may bo found either thinor thickened; there may bo an unequal consistence in differentparts; other cysts may be found softened and perforated, whilestill others may be found covered with small vegetations. Insome cases the internal surface of the cyst wall was foundcovered with a layer of fibrin, while the external surface of thewall showed a partial desquamation of the epithelium, and thuswe may explain the possibility of the formation of adhesionstaking place by means of friction.

Microscopically various conditions of the walls may bo found.In some cases sarcomatous degeneration of the wall has beenrecorded. In other cases the microscope showed typically atubercular follicle with nuclear zones grouped around a giantcell. In a case reported by Bumm the connective tissue mak-ing up the wall was found infiltrated with small cells. Sec-tions colored with methylene blue showed the presence ofbacteria, among which groups of cocci and bacilli were found.

As to the lesions which are present in the neighlx>rhood ofthe cyst, we may mention, in the first place, ascites, whichvisually is not very abundant, and also peritonitis, which mayeither bo generalized or localized. In an infected focus suchas wo have in the suppurating ovarian cysts wo can read-ily explain the continual inflammatory attacks which occur.Localized peritonitis is by far the most frequent, and it is thisprocess that gives rise to the formation of adhesions whichbind the growth to the surrounding parts, such as the intes-tine, the abdominal wall, or the mesentery. These adhesionsmay bo very extensive, thick, and their vascular supply is veryabundant.

In a case reported by Page an abscess of the cellular tissuein the retrocecal region was found. In a case rejxvrted byFeraud there was a cystocele, rectocolo, and an increase in theprolapsus of the uterus which was present. In most cases theuterus will be found high up in the pelvis, and in most cases itis pushed either to one side or the other. A certain numlvor ofcases of perforation of the intestinehave been mentioned. Thediaphragm is often hindered in its respiratory movements, andthe iliac vessels ami the vena cava are frequently compressed.Pressure of the lumbar plexus and the sacral plexus may l>o ofa sufficient intensity to produce the lesions of peripheral neu-ritis in the lower limbs, resulting in a very marked muscularatrophy. In one case reported by Feraud a pleuritic collection

4 cumston: septic infection

on the left was found, and the reporter considers it as due to ahindrance in the lymphatic circulation of the abdomen.

In considering the pathogenesis of septic infection of ovariancysts, the first question to bo considered is whether the liquidcontents of the cyst, before infection by foreign elements hastaken place, does not contain its micro-organisms, which wouldalmost surely end in a suppurative process. Clinically we maydeny this, because if such were the case every ovarian cystwould naturally end in suppuration. And, what is more, if itbe admitted that the liquid contents of a cyst, before any con-tagion has taken place, are already septic, how can wo explainthese cases of rupture into the peritoneal cavity which willneither result in inflammation nor in symptoms of infection ? •

Bogdanick has re|>ortod the case of a very largo ovarian cystwhich contained twenty litres of fluid and which rupturedinto the j>oritoneal cavity after traumatism. Abdominal sec-tion showed that there were two rents in the cyst wall, measur-ing several centimetres, one being on the anterior aspect, theother on the posterior aspect of the cyst. Careful examinationfailed to reveal the slightest traces of peritonitis, and the pa-tient was perfectly well two weeks after the accident.

Lannelongue mentions another similar case. A woman whohad an ovarian tumor was twice tapped in order to withdrawthe liquid contents, but the cyst soon refilled and the pa-tient entered the hospital. On account of the persistency ofthe fluid Lannelongue decided to operate, hut before doing soho wished to keep this patient under observation for a fewdays. But his surprise was great when, on the day after thepatient’s entrance into the hospital, he found that the cyst hadcollapsed and that symptoms of a peritoneal collection hadsuddenly taken the place of those given by the cyst; and infact during the night the latter had hurst and had emptied itscontents into the peritoneal cavity. There was no reaction, novomiting, and no pain after this rupture. The liquid becameprogressively ahsorl>ed, and six months later the patient wasfound in good condition. The abdomen was soft and the vagi-nal culs-de-sac were perfectly free.

If we now examine the experimental side of the question,wo will find still more proofs of the perfect asepsis of the liq-uid contents of those cysts. This has been demonstrated byChautTard and Widal, more es|»ocially in cases of hydatidcysts, but they have also demonstrated it in ovarian cysts.Knowing, then, that the liquid contents of these cysts is asep-tic, wo might ask the question whether this liquid itself might

OF OVARIAN CYSTOMA. 5

not be a good culture medium for bacteria when they gain en-trance within the cyst.

The above-mentioned writers have made comparative inocu-lations of peptonoid beef tubes and in tubes containing the liquidcontents of a cyst. These experiments, which were carried onwith the staphylococcus and streptococcus, the bacteriumcoli and the bacillus of typhoid fever, showed that the tubescontaining the fluid from the cyst, as well as those containingthe peptonoid broth, gave beautiful cultures of the variousorganisms inoculated.

From the above-mentioned facts it may be said that if theliquid contents of an ovarian cyst are not contaminated bybacteria they will remain aseptic and will undergo no change;but if, on the contrary, microbes attack a cyst and enter it. itscontents will serve as an excellent culture medium and symp-toms of infection will soon appear. But the human organismwill take on the offensive and will react against the bacteriawhich have infected tin* cyst; leucocytes come through thewalls of the vessels and attack the invading microbes, and thuswo have the transformation into pus of the liquid contents.

It is well known at the present time that suppuration is notto be considered as a special reaction of the organism, producedby certain infective germs; and also it is known that it is notconfined alone to certain types of bacteria, and that it is asimple pathological process. The most varied kinds of bac-teria may produce it, be they pathogenic or saprophytic. Thus,for a suppuration caused by pyogenic organisms other than thestaphylococcus and streptococcus, we know that suppuratingmeningitis is produced by pneumococcus, that the gonococcuswill produce a suppurating arthritis, that empyema can l»e pro-duced by the bacillus of tuberculosis, and that the bacillus oftyphoid fever can produce osteomyelitis. In the case of sapro-phytic infection, in order that the liquid contents of an ovariancyst be preserved from purulent changes, it is necessary thatit remain free from both pathogenic and saprophytic organisms,and if they find entrance they an* the cause of suppuration.

From what we have said we may conclude that wo have twokinds of septic infection of ovarian cysts—viz., the pathogenicinfection and the saprophytic infection.

Pathogenic and saprophytic organisms enter ovarian cystsin various ways. Puncture, incision, and drainage are oftenthe means of their direct invasion from the exterior; and weshould always bear in mind that the deep layers of the epider-mis contain bacteria in large quantities, more particularly the

6 CUMBTON: SEPTIC INFECTION

staphylococcus albus, the latter presenting a very great resist-ance to all manner of disinfection, and which by the above-mentioned operative interference may be pushed directly intothe interior of the cysts. But in a great number of instances,as puncture is discarded by the majority of the profession, thepatient contains the agent of the septic process under consid-eration. The germs did not come from without, but from theinterior of the organism, and it may l»e called a true auto-infection, which can take place in one of three ways: Firstly,by means of the blood, in which case the infection is eitherdirect, produced by phlebitis which extends up to the cyst, orit may be indirect, in which case the infectious elements arecarried in the general circulation into the tumor by moansof its pedicle. Secondly, infection may bike place by thelymphatics, in which case the lymphatic channels act as thecontaminating canals and allow a direct introduction of thegerms into the interior of the cyst up its hilum. Thirdly, wehave infection through adhesions, which are plentifully sup-plied in new-formed vessels which are intimately connectedwith those in the walls of the cysts and thus allow an easytransportation of the bacteria.

Thus let us suppose that a woman with an ovarian cyst be-comes stricken with an intercurrent infectious disease; by theindirect way of the blood, by the aid of a branch of the abdom-inal aorta, the utero-ovarian artery, the septic matter may bobrought to the cyst and infection result. Thus we have onrecord cases in which influenza, typhoid fever, gonorrhea,tuberculosis, and pneumonia have been the cause of septic in-fection of ovarian cysts. In other cases puerperal infection,septic remains of an abortion, have probably produced suppu-ration in the cyst by means of an infecting phlebitis—strepto-coccus phlebitis of the uterine veins extending as far as thepampiniform plexus, and from there reaching to one or severalveins in the wall of the cyst by the lymphatics. The lympha-tics of the uterus form an anastomosis with those of the ovary,and thus we have a direct route free for the invasion of thecyst by the pyogenic germs. In other cases the adhesions mayprobably furnish the means of transport for the organisms, andin one case infection took place from a cystitis. Adhesionswith the intestine or ap|>endix may permit of the arrival ofsaprophytic germs into the cyst, these saprophytes always ex-isting in large numl>ers in the intestinal cavity.

Sutton, Giles, Pozzi, and others believe that infection ispossible by adhesions with the tubes in cases of pyosalpinx.

7OF OVAKIAN CYSTOMA.

Keating and Coo have put on record a case in which infectiontook place by means of adhesions binding an inflamed appen-dix to the ovarian cyst. These three routes of infection beingadmitted, it is quite logical to ask if there are not other circum-stances which may favor infection.

Locally traumatism, the injection of corrosive substancessuch as iodine, torsion of the pedicle—which, on account of thevascular and nervous phenomena which it brings al>out. weak-ens the cell elements—alter vitally the tissues and thus renderthem less apt to resist microbe invasion. In one case sarco-matous degeneration of the walls of the cyst, producing alocus minor is resistentia J

, was the cause.Thrombosis of the vessels of the cyst wall is not in all proba-

bility a factor in the production of simple rupture of ovariancysts, but hemorrhage due to a papillomatous change is impor-tant, because a slight disturbance in the circulation or a hemor-rhage is alone quite enough to set up inflammatory phenomenain a cyst, or oven gangrene. Cases are on record in whichboth suppuration and gangrenehave resulted after hemorrhageinto the cyst had occurred.

In other cases pregnancy or labor has played a large parton account of the abdominal congestion produced, as well asby the contusions that the cyst received during gestation orlabor.

Labor and the puerperiutn certainly offer great opportunitiesfor septic infection or gangreneof ovarian cysts. This is espe-cially true of pressure or laceration of the tumor during laboritself. The application of the forceps or manual extraction ofthe placenta, with the added possibility of infection from thelochia, an endo-, peri-, or parametritic inflammatory process,are factors enough, each one of which is in itself sufficient tocause septic infection of an ovarian cyst.

The danger is still more increased when the tumor is a der-moid, or if during labor perforation of the cyst takes place;and, previous to a labor or miscarriage, gestation alone playsquite a large part as a predisposing factor to inflammationgenerally.

Mangold states that bacteria may enter a cyst by directtransportation through the venous circulation in cases of septicpuerperal uterus, while, on tin* other hand. Bouilly believesthat the bacteria are transported through the lymphatics of theovarian ligament from the infected endometrium. For thesame reason hyperemia of the pelvic organs and menstruationmay facilitate infection. During the menses it may happen

8 CUMSTON: SEPTIC INFECTION

that the reflux of the bloo<l may introduce germs, which nor-mally are present in the vagina, into a previously aseptic uter-ine cavity.

The germs usually found in the vagina are certain diplococci,several varieties of staphylococci, and occasionally strepto-cocci, and when once these organisms have entered the uterinecavity we can easily see how they may attain a cyst.

This theory has heen put forward hy Schauta, and he saysthat the process which takes place in cases of gonorrheal-peri-tonitis may also he applied to the infection of ovarian cysts.In the former case the gonococcus is deposited in the vagina,and he can only extend his territory hy means of segmentation.The internal orifice of the cervix forms a hindrance to the en-trance within the uterine cavity of the secretions of the cervix,hut during menstruation the transportation of the gonococcimay take place hy means of menstrual reflux. If to menstru-ation we add coitus practised during this time, wo certainlyincrease the chances of infection. In the first place, the con-gestion within the abdomen is increased, and during the vene-real spasm the contractions may possibly produce a certaindegree of aspiration from the vagina toward the uterus.

Mangold is also of the opinion that coitus during menstru-ation or the puerperium is an etiological factor in septic infectionof ovarian cysts, while, on the other hand, Bouilly affirms thathe has never seen a case to which the above theory might apply.

The general condition of the patient may also have its influ-ence. Debility, intoxication of the organism, or had hygienicsurroundings will certainly place the organism in a moremarked state of receptivity, and both pathogenic and sapro-phytic organisms make greater havoc in such jKiople. It isalso very probable that certain infectious diseases in which thespecific microbe has heen demonstrated in the pus act in thesame way, the suppuration in the cyst l>eing, so to speak, a

secondary infection arising in a weakened organism.The pathogenesis of aseptic pus of ovarian cysts only means

that it is a different stage of the same process, l)ecause in thebeginning of the lesion, in all probability, the pus containedbacteria. The same ways of infection, the same determiningcauses which predominate, are also present in cases in whichthe pus is aseptic, and if bacteriological examination demon-strates that the pus is free from organisms, it simply meansthat they have disappeared or that they have already died offand can no longer he grown on artificial media nor can he seenmicroscopically in stained specimens.

OF OVARIAN CYSTOMA. 9

Wo have nothing now in the above fact, and the same phe-nomena take place in abscess of the liver as well as in certainpurulent foci produced by the tubercle bacillus. Why the bac-teria die is as yet an open question, but nevertheless it is cer-tain that this is the case.

Regarding the symptomatology of ovarian cysts, we may saythat they give rise to local and general phenomena. Local phe-nomena are not. identical when the cyst is in a latent and whenit has arrived at what may ho termed the pelvic or abdominalstate. In the beginning there are no marked signs, and dis-turbances of the menstruation and indefinite pains in tla* lowerabdomen have only a very slight value. Liter on, by palpa-tion, wo can distinguish a growth which is seated laterally andextending more or loss beyond the median line. The area overthe tumor gives dulness on percussion, while sonority will hefound all around it.

If the cyst is very large and unilocular, fluctuation maysometimes ho easily made out. If the cyst is a multilooularone wo will find by palpation an irregular tumor covered withbosses, while attentive examination will show in many casesthat in certain parts of the cyst fluctuation is present while inothers it may ho wanting. As long as the tumor remains inthe pelvis an elastic and resistant mass, which is independentof the uterus, may ho easily found by manual palpation; orwhen the cyst has become large and has extended up into theabdomen, wo may no longer he able to reach it by the vaginalfinger, and it will reveal the fact that the cervix uteri is highup and reached with difficulty. The alnlomen increases in size,while the lateral projection becomes more pronounced in themiddle lino and may extend up as high as the false ribs, push-ing hack the diaphragm; the bladder, rectum, stomach, ute-rus, iliac vessels and the vena cava, and the sacral and lumbarplexus show signs of compression. The general health of thepatient begins to deteriorate. The general symptoms producedby ovarian cysts is difficulty in breathing, producing dyspnea;dysuria, incontinence of urine, vomiting, constipation or diar-rhea, symptoms of chronic uremia, edema, and more or lessviolent pains are present; pronounced loss of flesh, with a pecu-liar expression described under the name of “ovarian facies,”is also to be noted.

If we consider the symptoms presented by an infected cyst,we should immediately ask if there are any phenomena, eitherlocal or general, which may facilitate a diagnosis that suppu-ration has taken place. Generally speaking, this cannot be

cumston: septic infection

(lone, and it may he said that there is no symptom which in itselfcan indicate to the surgeon that an ovarian cyst has becomeinfected. But there are certain symptoms which may possiblyhelp us in making a diagnosis when septic infection of a cysthas occurred, besides the symptoms of cysts generally speak-ing. As local phenomena wo will have rapid increase in sizeof the abdomen, and accompanying this there will usually hea development of the subcutaneous veins. The patient willcomplain of very sharp, nearly continual pains in the abdomen,which may he either spontaneous or produced by the slightestprovocation. Ascites may he present, hut more usually thereis peritonitis. The tumor will he found only slightly movable,and fluctuation is not often so marked as in ordinary cysts, onaccount of the greater density of the fluid contents.

As Penrose has pointed out, a suppurating ovarian cyst maysometimes contain gas, either from communication with theintestine or from decomposition of the contents, and in suchcases the usual tumor dulness will ho replaced by a tympaniticnote. But when infection has occurred the general phenomenaare by far the most important; the health is rapidly under-mined and the patient loses flesh, the mucous membranes arepale, and the skin has a cachectic color; edema, great thirst,and profuse perspiration during sleep are complained of; inmost cases fever is continuous, the mercury marking in theneighborhood of 38.5° C., with an evening rise and morningremission. In other words, we have the classical picture ofsepticemia. Anorexia and vomiting has been noted in a num-ber of cases. In some it occurred and later on the cyst per-forated, its contents being emptied into the general peritonealcavity. But in many cases no rupture had taken place andthe vomiting must he wholly attributed to septic infection ofthe neoplasm. Vomiting was present in some instances at theonset orsome time before the septic process was diagnosticated,while in others this symptom first appeared during the courseof complication and when there were a number of symptomsindicating the presence of suppurative phenomena.

When vomiting is present it is usually insistent and severe,or even incoercihle. The vomitus may he greenish in color, orthe coffee-ground type may he present in some cases. Nauseaoften precedes vomiting, either with or without rupture of thecyst having taken place; and in one reported case, where nau-sea without vomiting appeared some time before the symptomsof septic infection of the cyst, necropsy revealed the presenceof an old gastric ulcer.

11OP OVARIAN CYSTOMA.

Diarrhea lias been noted in many cases, with or without rup-ture of the cyst; it may occur at the onset or during thecourse ofthe septic disturbances. It may also give place to constipation.In one case constipation appeared at the onset, and then a severediarrhea was substituted which lasted several weeks. Consti-pation, which is often quite obstinate, may be present insteadof diarrhea, and may occur at the onset of the septic process.

Insomnia, or even delirium, and later on, if the case goesbadly, there will ho a profound prostration and semi-coma.Albumin may be present in the urine, and indol will nearlyalways be found if looked for.

Dyspnea is quite frequently present, and may precede theseptic phenomena or appear at the onset and continue through-out the progress of the septic complication. Broncho-pneu-monia and pleuritis (metastatic?) have been reported, andin these cases it was duo to a compression of the lung, one ofwhich presented adhesions and an inflammation of the dia-phragm. The dyspnea may lie accounted for in some caseson account of the acute purulent peritonitis following ruptureof the infected cyst.

Indicanuria may, according to Kielman, have considerablediagnostic value, and ho says that it occurs regularly in allcases in which there are purulent collections in the body, andmay consequently he considered as a very valuable sign, proofthat there is a latent suppuration present. Personally, intwo cases of infected ovarian cysts we have found indol pres-ent in the urine. As rare complications of septic infection ofovarian cysts we may mention edema of the external genitals,of the lower extremities, phlebitis with or without rupture ofthe cyst; motastases in various joints, and ileus, have also beenreported.

The diagnosis of septic infection of ovarian cysts is not easilymade, and we should always have present in our minds thevarious diseases which may simulate this condition. Weshould consider two classes of conditions—viz., those in whichthe infected cyst presents only the symptoms of an ordinarycyst, and, secondly, those in which the suppurating processmanifests its presence by local and general symptoms whichare more or less marked. In the first case it is impossible tomake differential diagnosis with a simple cyst of the ovary,because examination and symptomatology are identical in bothinstances; and for this reason a septic infection of a cyst mayho mistaken for various other affections which are similar intheir symptoms to ordinary ovarian cysts.

12 cumston: septic infection

In ascites the shape of the abdomen is not the same, localisethe flanks have u perfectly symmetrical projection. By per-cussion wo find dulness, which is replaced hy a tympanitic notewhen the patient changes her position. Hydrosalpinx usuallygives rise to an exquisite pain, which is sudden and localized inthe region of the diseased organ; and thus we are always ableto elicit more former trouble of the genital apparatus in thepatient. A fibrocystic tumor of the uterus will show by palpa-tion that the tumor is firmer thanan ordinary cyst; it is directlyconnected with the uterus and participates in all the move-ments given to thatorgan. A unilateral hydronephrosis wouldnaturally give rise to serious troubles in the urinary apparatus.And, lastly, in cases of cysts of the mesentery or of the liver,the surgeon should remember that in such cases the tumor de-velops from above down and is independent of the genitalorgans, whereas in the class of cases that we have now to ex-amine septic infection of the cyst is accompanied by specialsymptoms. Nevertheless the diagnosis may ho very uncertain.When the cyst, during its latent period, gives rise to no localsymptoms, but has already produced toxic symptoms in thebody, the question of a typhoid fever, an acute miliary tuber-culosis, or some infectious disease may be considered, and suchcases have been reported by Feraud and Goodoll; ami it is onlyby the local manifestations of the growth that all doubts maybe removed as to the real cause of the trouble.

When wo are dealing with an infected cyst which is situatedhigh up in the pelvis or high up in the abdomen, it may hemistaken for a large number of conditions, and, in the firstplace, we should consider the question of a malignant transfor-mation of an ordinary cyst of the ovary or a neoplasm of thisorgan. In these cases we find locally by palpation that theyare harder, more consistent, and firmer tumors than in cases ofan infected ovarian cyst, while the general sj’mptoms in mostinstances are loss acute and less rapid. If the malignant pro-cess has extended we will certainly find enlarged lymphaticglands. Cases of torsion of the pedicle have, like suppuratingovarian cysts, a rapid increase in size of the abdomen and asudden and very sharp pain, hut there are two important signs,which have been doscril>ed hy Reboul, which will allow ofmaking an exact diagnosis l»eforo operating, and these are:first, by auscultation a systolic souffle will be heard, situatedover the painful point (that is to say, over the pedicle of thecyst); and, secondly, by palpation wo will have a movement

OF OVARIAN CYSTOMA. 13

eu masse, of the tumor, which gives the sensation of heaving,which coincides with the arterial pulse.

In cases of suppurating ovaries or pyosalpinx we will be ableto elicit former disturbances in the adnexa, while suppuratinghydatid cysts of the ovary, which are only mentioned heremore as a curiosity than anything else, will give rise to thecharacteristic trembling which is found on palpation in thesecases. Intestinal occlusion begins very suddenly, and soon theabdomen increases in size. A tympanitic note will Ikj foundeverywhere, and Urn distended intestinal coils may l>e outlinedthrough the abdominal wall in these patients. Fecal vomitingand absence of feces and gas per rectum, with cold skin andlowered temperature, are sufficient signs for the diagnosis.

In the generalized peritonitis the pain extends over the entireabdomen and produces severe pain, vomiting will occur, andabdominal palpation is impossible, and if vaginal examinationbe made no sign of any tumor will l>e present. Fever is high,temperature reaching at about 10° C. without any morningremission, and if, in a case of infected ovarian cyst, it remainscontinually up, in peritonitis we must have at a given time adecrease by lysis.

The differential diagnosis with encysted peritonitis is mostdifficult, especially when the collection is considerable inamount. The means for differentiating are not very numer-ous, and Spencer Wells says that he knew none. However, acertain amount of information may Ik» drawn from the irregu-lar shape of the abdomen, with a more marked projection in agiven direction while the rest of the abdomen remains de-pressed, and also the history of a slowly progressing diseasewith former attacks of peritonitis and the peculiar sensationgiven by the intestine on palpation.

Periuterine hematocele which has undergone an inflamma-tory process will reveal to the examining finger within thevagina a swelling which fills Douglas'pouch.

When we are dealing with an abscess of the broad ligamentwo have one pathognomonic sign, which is the “abdominalplaque,” and is felt as a hard and resisting mass situated deepin helow the abdominal wall and projects immediately abovethe crural arch.

Abscess of the iliac fossa* is apt to be adhering to the integu-ments, and is felt superficially independent of the deep organs.

Generally speaking, the prognosis of the septic infection ofovarian cysts is serious. If the ordinary cysts are themselvesserious, if they produce serious symptoms, if, on account of

14 CUMSTON: septic infection

their epithelial nature, they are, so to speak, balancing betweenvirulence and perfect innocuity, it must 1)0 rememl)cre(l that incases of infected cysts the chances of a fatal termination arevery much greater. Patients who are subjects of infected cystsof the ovary run great dangers, and before surgical interferencebecame a current practice in this class of cases death was themost frequent outcome.

Such a large quantity of pus as is found in suppuratingcysts is with difficulty supported by the human organism, andthe disorders that it produces are too considerable for a bodyto resist, and, as already stated, cachexia and prostration areprominent in a largo number of cases. And what is more, theprogress of the symptoms is in most cases extremely rapid,usually not extending over a few months.

We must nevertheless bear in mind that things do not goquite so rapidly in every instance, and instead of this quickprogress a more latent form of symptoms of subacute orchronic septicemia may be present. Some patients have evenremained sick for some time without presenting any seriousdisorders, and in one case reported by Feraud the suppurationhad existed eighteen months and still the patient was in a faircondition. One thing which is certain is that those purulentcollections, when once formed, will never disappear spontane-ously, and sooner or later they will either end in death by acutesepticemia, which, according to Herman, is the most frequent,or by generalized peritonitis, which may take place in one ofthe two following manners—viz., by an extension of the in-flammation to the surrounding structures, or from rupture ofthe walls of the cyst if no peritoneal adhesions are present, inwhich case the pus will bo spread throughout the general peri-toneal cavity. The same phenomena take place when wo aredealing with sterile pus; its consistence, density, and consider-able quantity prevent’it from being absorbed, and when sud-denly emptied into the peritoneal cavity it will disturb thecirculation and thus produce a shock which is most favorablefor the development of inflammation.

If rupture of the cyst should take place when peritonealadhesions are already present, the eruption of pus will takeplace in the neighboring hollow viscera, more particularly inthe digestive tract. Serious disturbances, either direct orreflex, may result and death may occur within a few days,But in the majority of cases a prolonged suppuration is sot up,which little by little brings the patient into a hectic con-dition. If the ruptured cyst is a dermoid the hair and solid

15OK OVA HI AN CYSTOMA.

matter, more particularly the teeth which have been emptiedout along with the liquid contents, may become the cause of aparticular series of accidents. For example, in certain cases,if foreign bodies from the cyst which have entered the bladderbecome the nucleus of a vesical calculus, or else if they becomeengaged in the ureter, they cannot pass down it and conse-quently become an obstacle to the flow of the urine. The cys-titis produced by a communication between a dermoid cyst andthe bladder is always very severe, and the inflammatory pro-cess, extending upward to the kidney, will result in veryserious renal lesions.

If rupture of the cyst takes place into the vagina or throughthe abdominal wall, the patient is liable to chronic septicemia.Nevertheless in these cases, as well as in those in which rup-ture has taken place into the hollow viscera of the neighbor-hood, a happy outcome may bo brought about and the condi-tion may finally be caret I after a certain length of time, becausethe walls of the cyst collapse, become atrophied, and the secre-tions dry up; but in such a case we have an exception, and, ifthe surgeon does not wish to see his patient die, interference isthe only proper thing.

At the present time the removal of cysts of the ovary,whether they have become infected or not, is the proper courseto pursue. As soon as suppuration Ims been recognized, oreven suspected, immediate interference is to l»e recommended.To wait is to place one’s self voluntarily in bad condition amitakes away much chance of success. If we operate early thepatient is in better general condition to undergo surgical inter-ference, and if adhesions are present they are naturally softer,easier to break down; and consequently an operation underthose circumstances is less difficult and of shorter duration,which, as we all know, are some of the chief elements of suc-cess.

Operation for the removal of ovarian cysts which are the seatof a septic infection may he divided into four stages, as follows:I. Incision of the abdomen. 2. The breaking-up of adhe-sions and ligature of blood vessels which they may contain,and then the pus may he removed by the trocar, and not withthe knife, because if the cyst is incised pus will immediatelyflow out and the wound will very likely become infected by theseptic material. The third stop in the operation is the extrac-tion of the cyst through the wound, and in doing this thesurgeon should he careful to avoid infecting the abdominal in-cision at the time he is drawing the pocket through; but this

16 cumston: septic pnfection

complication may bo easily avoided if aseptic gauze spongesare tightly packed around and inside the line of incision.Next comes the ligature of the pedicle and its section, afterwhich it is dropped into the abdomen; and here again wo mustremember that the ligature may become infected, and stoutcatgut is, according to our way of thinking, the proper materialto use.

The fourth stop of the operation consists, firstly, in thecleansing of the peritoneum, which should bo done with groatcare, especially when the operative field has run any chance ofinfection. If this has occurred it ap]>ears to us that a freeirrigation of the peritoneum is proper, but it should be donewith care and the liquid employed should bo a warm normalsalt solution. We should be careful to limit the irrigationto the subumbilical portion of the peritoneal cavity, and a backflow of the liquid toward the diaphragm should be preventedby having the operating table perfectly fiat and the thoraxslightly raised. The temperature of the fluid should be :i7° C.After the cavity has been carefully cleansed the abdominalincision is to be sutured, but we think it more prudent toalways drain those cases by placing the tube at the mostdependent part of the wound.

The question that arises is, have we any contraindicationsfor operating on ovarian cysts which are the seat of septicinfection? If the patient is pregnant we believe that this con-dition is a decided indication for operating, because both themother aud child are greatly imperilled by the presence of thispathological condition. In the first place, miscarriage maytake place, and in a case reported by Feraud the mother andfetus both died.

Labor may also bo greatly hindered by the presence of ucyst, or may even rendered impossible; and even if this takesplace without trouble, when the uterus becomes emptied it mayproduce a change in the relationship of the cyst to the sur-rounding organs a d produce a torsion of the pedicle, or thecyst at the time of delivery may prevent involution fromtaking place and thus give rise to very serious hemorrhage.We are also of the opinion that pregnancy may cause infectionto take place in ovarian cysts as well as cause thorn to rup-ture. Consequently, if we wish to prevent the patient fromthe jrossible occurrence of these serious accidents, ovariotomyshould bo performed regardless of pregnancy, and the life ofthe mother is thus insured, while in many cases pregnancy willgo on to term and a healthy child will l>o delivered.

17OK OVAKIAN CYSTOMA.

Davis says: “In cases of pregnancy com plicated by ovariantumor but one treatment is advisable, and that is the removalof the tumor. The best time for such operation is about thefourth month of pregnancy. No period of pregnancy, how-ever, positively forbids ovariotomy, and in all cases removal ofthe tumor is indicated.”

Penrose, Dsirne, Flaischlen, Anderson, Terrilion, McMurtry,Acconci, and Mangiagalli are all in favor of the removal ofovarian cysts during pregnancy, and, lastly, we should citefrom the excellent text book on obstetrics by Ribemont-Des-saignes and Lepage the following, viz.: “That during preg-nancy certain complications, such as peritonitis, torsion of thepedicle, or rupture of a cyst, demand immediate interference,”and the writer would add that septic infection of an ovariancyst complicating pregnancy imperatively demands immediateoperation. As to whether ovariotomy should be performed ona woman who presents puerperal septicemia, we think that thepuerperium should not be considered as an absolute contra-indication for surgical interference, and this proposition isborne out by the case reported by Leroy des Barren, who savedhis patient by operation. It is certain that a patient presentinga puerperal septicemia is most excellent soil for the develop-ment of bacteria, and consequently if operation can with goodreason be delayed it is better to do so; but wo are absolutely infavor of operating where the septic symptoms are urgent.

There is one absolute contraindication for the complete re-moval of cysts, and this is when we find ourselves in the pres-ence of old and tough adhesions binding the tumor to thesurrounding parts, and in these cases there is much danger ifrupture of these fibrous bands is undertaken. Under thesecircumstances, both on account of the difficulties in an operationand the necessity of long and laborious work, it has beenadvised to perform an incomplete extirpation. Keith in onecase found the peritoneum hard and cartilaginous and fullyone-third of an inch in thickness, and it was so incorporatedwith the cyst wall that an attempt to separate it was not made.The pus was washed out and the cavity drained. The patientrecovered.

We think it advisable in these cast's to suture the borders ofthe incised cyst and then drain the latter, just as we wouldin Cases of abscess. But we also think that in addition to thedrainage through the abdomen it is more prudent to incise thevaginal cul-de-sac and obtain the drainage by this route as well.Naturally ovariotomy with complete extirpation of the cyst is

18 CUM3TON: BBPTIO INFKCTION OF OVARIAN CYSTOMA.

tho ideal treatment when it is possible, but in other cases inwhich danger is incurred from tho presence of tough adhesions,the above treatment, we think, is indicated.

871 Beacon street

LITERATURE.

1. Jarjavay: bulletin de la Societe anatomiquo, 1853.2. Meykr: Deutsche Klinik. No. 9, 1800.3. GOSSKLIN: Gazette des Hopitaux, 1869.4. Rokitansky: Wiener Med. Press**, 1870.0. SchOi.kr; Deutsche Zeitscbrift ffir Chirurgie, 1870.0. Weil-Breisky: Prager Med. Wochensohrift, 1878,7. Sims: British Med. Journal, 1879.8 WaLLE: Ueber die Perforation d«*r Blase (lurch Dennoidkystonie.

Dissertation, Leipzig, 1881.9. Tait: Diseases of the Ovaries. 1880.

10. Brown: Suppurating Ovarian Cyst. Pacific Med. and Surg Jour-nal. 1887.

11. De Roubaix: Kyste ovarique multiloculaire; Ovarite suppuree.Presee medicale Beige, 1887.

13. Price: Double Pyoealpinx with Coexisting Ovarian Cystoma on BothSides. American Journal of Obstetrics, vol. xx.

13. Sack#:: Kyste suppuree de I’Ovalre. Journal de Medicine. 1887.14. Byford: Suppurating Ovarian Adenoma. American Journal of

Obstetrics, 1887.15. BOLDT: Suppurating Ovarian Cyst in a Chihl. Proceedings N. Y.

Path. Society, 1889.10 Miller: Suppurating Cyst; Operation; Recovery. Trans. South

Carolina Med. Association, 1889.17. Pf’.AN: Leqons de Clinique chirurgicale, |»ages 888-890, 1888.18. Clay: Acute Ovaritis followed by Suppurative Peritonitis; Death.

Lancet, vol. i., 1890.19. PfcNAUD: Kyste dennoidesuppuree de 1 Ovaire Bull, de la Soci6t6

anatomique de Paris, 1889.20. Ribemont-Dessaiones kt Lepage: Precis d'Obst6trique, 1893.21. Skene Keith: Text Book of Abdominal Surgery, 189422. Mangold: Ueber die Infection des Ovarialkystome. Dissertation,

Basel. 1895.23. Keating and Coe: Clinical Gynecology, 1895.34. Davis: Treatise on Oljstetrics. 1890.25. Merge und Kronig: Bakteriologie dee weihlichen Genitalkanals,

1897.26. Greio Smith: Abdominal Surgery, vol. i.. oth edition. 1897.27 PfeRADD: Kystes suppurees de I’Ovaire. Thdse, Bordeaux, 1897.28. Penrose: Text Book of Diseases of Women, 1897.29. Keen: Surgical Complications and Sequels of Typhoid Fever, If>9B.30. Pfannenstiel in Veit’s Hundbuch dor Gynakologie, Band ill.. 1898.81. LABAdie-LaoRAVE et Leoveu: Trait 6 medioo-ohirurgical de Gyn6-

cologie, 1898.33. Anderson: Laparatomy during Pregnancy. American Practitioner

and News. May 15, 1898.

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