-•CDMPtWENTS OF THE AUTHOR. FOR REVIEW.’ Papillomatous Cystic Tumor of Ovary, With a Hernial Pouch Developed in the Ci- catrix of the Abdominal Wound from a Former Ovariotomy. BY L. H. LAIDLEY, M.D., PROFESSOR OF GYNECOLOGY BEAUMONT MEDICAL COLLEGE; SURGEON TO PROTESTANT HOSPITAL; CONSULTANT TO ST. LOUIS FEMALE HOSPITAL. Read before the St. Louis Medical Society, March 10, 1888. Reprinted from the Journal of the American Medical Association, April 14, 1888. CHICAGO: Printed at the Office of the Association 1888. Papillomatous Cystic Tumor of Ovary, With a Hernial Pouch Developed in the Ci- catrix of the Abdominal Wound from a Former Ovariotomy. BY V L. H. LAIDLEY, IvI.D., PROFESSOR OF GYNECOLOGY BEAUMONT MEDICAL COLLEGE; SURGEON TO PROTESTANT HOSPITAL; CONSULTANT TO ST. LOUIS FEMALE HOSPITAL. Read before the St. Louis Medical Society, March 10, 1888. Reprinted from the Journal 0/ the American Medical Association, April 14., 1888. CHICAGO: Printed at the Office of the Association 1888. PAPILLOMATOUS CYSTIC TUMOR OF OVARY, WITH A HERNIAL POUCH DEVELOPED IN THE CICA- TRIX OF THE ABDOMINAL WOUND FROM A FORMER OVARIOTOMY. Mrs. C., aet. 39, American, married, had one child which is now eight years old, gave the following his- tory : She was of healthy parents, menstruated at 14 years, was a healthy girl, married at 22. Eight years ago she had an ovarian tumor removed from the left side (it was a large, multilocular, benign ovarian tumor). One year after the operation she was delivered of a child at full term. The recent operation and the pregnancy developed a large her- nial pouch, which allowed the bowels to protrude, forming a tumor as large as a child’s head at full period. No instrument could be made to keep the hernia in position, and for the past two years she was confined to the house. Eleven months prior to my first visit another tumor made its appearance, beginning in the right iliac region ; it developed rap- idly, occupying a position on the right side which could readily be felt through the hernial sac. Five months after its first appearance a “magnetic doc- tor” was allowed to treat the case, which he did by “the laying on of hands,” in this case rather roughly, as the results will show. This doctor claimed “to coax the fluid out through the Fallopian tubes.” When the tumor was pressed upon the patient no- ticed a great rush of water with blood from the vag- ina. This was repeated some time afterwards with the same results, the tumor almost disappearing. I was called last November, and found a deplora- ble state of general health; anaemic, appetite poor, 4 and patient so weak that she could not go from her chair to the bed without considerable fatigue. She had a distinct mitral bruit, weak and rapid pulse, temperature ioo° F. I continued to visit her for one month, feeding and administering medicines to build her up. She urged an early operation. An examination of the abdomen revealed a tumor in the right iliac region as large as the head of a child at full- period, which was fluctuating, movable, and easily defined by percussion. The uterus was plainly felt through the hernial pouch, separate from the tumor. Change of position did not influence its shape. No oedema of lower extremities, nor abdominal dropsy. Examination per vaginam showed a violent vaginitis with an opening through the floor of Douglas’ cul- de-sac, which allowed the passage of a sound in the direction of the base of the tumor. A fluid escaped through the opening; pressure on the tumor increas- ed the flow. That which escaped was white in color and mixed with blood. The amount of flow a day was estimated by the patient to be one pint. Diag- nosis : Cystic tumor of right ovary, probably uniloc- ular, with fistulous opening into vagina. An operation was performed December 6, with every antiseptic precaution, assisted by Profs. Coles and Graves, and members of the senior class of the Beaumont Hospital Medical College. An elliptic incision was made over the site of the tumor at least seven inches in length, the tumor exposed and the fluid drawn off, which was the same that flowed from the opening into the vagina. There was only one adhesion to the tumor; that of the extremity of the appendix vermiformis. This was torn off with the finger nail, and the end cauterized, completely con- trolling haemorrhage. (Greig Smith reports his hav- ing to remove the entire organ without serious re- sults.) The tumor was lifted from its broad base, which was transfixed at its attachments to the floor of the pelvis, the ligature tied, and all that remained 5 of the sac charred with a hot iron. Another ligature was placed below, and entirely around the pedicle, so as to close any opening that might exist with the fistula leading to the vagina. Papillomatous cystic tumor of ovary. Attention was now given to the hernial sac. Be- fore operating the line of incision was mapped out with iodine so as to remove all the pouch, and at the same time be able to approximate the walls. The 6 measurements before operation were seven inches by four and a half inches; a portion of the mesen- tery was attached to the cicatrix of the old wound, and it was ligated, cut and returned to the abdomen. The cavity was thoroughly cleansed of blood, the edges of the wound (closed with sutures less than one-half inch apart) were made to coaptate accur- ately, a drainage-tube was placed in the lower angle of the wound, the parts dressed antiseptically, and the patient put to bed. Reaction was complete within two hours, and for the first time since Novem- ber her temperature was less than ioo° F. A most aggravating nausea, which would not yield to any of the prescribed remedies, necessitated feeding per rectum from the first day. The temperature range for the first twenty-four hours was 990 to 99.8°, pulse 72 to 80. She did not sleep more than one-half hour during the night. On the second day the tem- perature continued less than ioo° until 9 p.m., when it rapidly rose to 103.8°; the pulse was rapid and weak, a dusky hue of the face was present with con- stant nausea, which forbad anything remaining in the stomach. Believing that I had an incipient peritonitis to deal with, I ordered calomel, grs. ijss, placed upon the tongue, which was the first retained since the operation. I continued the dose every half hour until ten grains was used, when I gave every hour mag. sulph. grs. xx—two doses were given. At 2 a.m. the next morning, by the use of a rectal tube, a half pint of thin fecal matter was expelled, which was followed by an enema, and the bowels thor- oughly cleaned out; flatus for the first time began to pass; the patient became free from pain and slept for six hours. The temperature went down to 99.6°, From this time she retained food, and showed noth- ing unusual in the progress of the case. On the sev- enth day the stitches were all removed (the tube having been removed on the fifth day) showing the 7 walls had united by first intention. A well-fitting truss, made from the cast of the abdomen, was ad- justed four weeks later, which allowed the patient to go about the room with comfort. Examined three Hernial pouch, showing the shallow secondary pouches in the peritoneum. months later, she was much improved in health, the fistulous opening into the vagina had closed, and 8 the operation had proven entirely satisfactory. I submitted the tumor for examination to I)r. Adolf Alt, who said it was of the papillomatous form. Coblenz believes that when ovarian tumors show a papillomatous development they invariably arise at the hilum of the ovary; this form is the most com- mon affecting these organs, and like villous growths elsewhere is not always malignant. In the malig- nant form papillary growths will be found in patches upon adjacent structures, or else the womb and broad ligaments are also involved in one cauliflower- like tumor. Tait observes that he has had two cases of ovariotomy in which he left large masses of papil- loma attached to the womb, yet in each case these masses wholly disappeared and the patients are both in perfect health. If this is true, may we not hope that this specimen is a benign tumor? This tumor was roughly handled five months be- fore the operation, causing the fistulous opening. May we not conclude, if it is true, as Tait and Ban- tock claim, that tapping hastens degeneration, and after an accidental rupture of such a cyst the peri- toneum will be found studded with patches of papil- lary cancer (hence they argue that ovarian tumors should never be tapped and that they should be re- moved in their earliest stages before any malignant transformations have taken place), that had this tu- mor been removed entire at the time it was injured, there would be no question that it would not return? Grand and Washington Aves.