lays down the following rules: 1. In labors com plicated with ovarian tumors, interference should not be long delayed. 2. In all cases we should first try to reduce the tumor, resorting to puno ture if this fails. 3. When the cyst-contents is too thick to flow through the canula, the cyst-wall should be freely incised. 4. All other operative procedures employed instead of evacuation of the cyst should be regarded as too dangerous, and should be rejected. 5. In the case of solid ovarian tumors, we have the choice between Caesarean section and perforation. The decision will depend upon the peculiarities of the case and the con science of the aecoucheur.
According to Olshausen, the indications for interference during preg nancy are threatening asphyxia, intestinal obstruction, inflammation or rupture of the cyst, and twisting of the pedicle. Three courses are open to the obstetrician, premature delivery or abortion, puncture, and ovari otomy.
1. Premature Delivery.—This has been advised by Barnes, and has been adopted by Douniairon, but the latter only recommends it when the tumor is lodged in the pelvis, and has solid or semi-solid, contents, as in the case of dermoid cysts; if the growth is small, we should prefer pre mature delivery to abortion.
2 Puncture.—Spencer Wells greatly prefers this to the premature in terruption of pregnancy, since by the latter method the child is sacrificed, and the mother's life is often jeopardized. When puncture is employed during the latter months or weeks of pregnancy, the relief experienced is often very marked; the procedure is usually free from the danger of wounding the uterus, which is only present when the pregnancy is unsus pected. It is especially indicated in awes in which the excessive distension of the abdomen causes dyspncea and threatening asphyxia, or where abor tion is imminent by reason of the pressure on the uterus. It may be necessary to repeat the puncture several times.
3. Ovariotomy has been performed several times during pregnancy by Marion Sims, Atlee, Wells, and others (9 cases); in one instance Wells accidentally punctured the gravid uterus, the patient being saved by Caesarean section, and Hillas had a similar experience. Braun and Schroeder reported 14 cases, in 4 of which pregnancy was not suspected. In 9 or 10 cases the operation was performed in consequence of actual or threatening rupture or inflammation of the cyst. Pregnancy was inter rupted in only four instances. [Quite recently, Mund( successfully per formed ovariotomy at the fourth month of pregnancy without interrupting its course.—Ed.] [Strati has published a number of clinical observations in regard to the complication of pregnancy by tumors, the statistics of the Berlin Clinic for ten years being used. During this period there were nineteen cases of ovarian tumors, 14 of the women being saved by ovariotomy, and 3 of these subsequently aborted. Among 84 cases of ovariotomy during
pregnancy, the mortality was only 9.5 per cent. He advocates strongly this operation in every instance, since the induction of labor sacrifices the child, and does not free the mother from the subsequent risks of ovario tomy, which are shown by the statistics quoted to be actually graver in the non-pregnant than in the pregnant female. Puncture of the cyst, he believes, offers no advantages over the radical operation, while it compli cates the subsequent removal of the tumors.
These views we believe will fairly represent the opinion held by the majority of obstetricians on this side of the Atlantic.—Ed.] In 1882 Cayla affirmed that ovariotomy may be performed during preg nancy under two very different circumstances: 1. When the condition of the cyst is such as to render us fearful that some accident may occur. 2. When some accident has occurred during gestation, sufficiently serious to make radical interference necessary. During pregnancy the accidents that may occur are rupture of the cyst, twisting of the pedicle, inflamma tion and suppuration. During delivery the cyst may rupture in conse quence of the uterine contractions, during the second stage; finally, dur ing the puerperium, inflammation and suppuration of the cyst may take place.
Heiberg divides the tumors, as regards treatment, into two classes, viz.: 1. Those that occupy the pelvis. In this case we should endeavor to reduce it from the middle of pregnancy on; if not successful, we should puncture if fluctuation is present, or perform ovariotomy if the former procedure is contra-indicated, otherwise premature labor may be induced.
2. When the tumor is abdominal, we should interfere if it developer rap idly, and causes severe pain. Ovariotomy should be resorted to during the first half of pregnancy, puncture during the second half. Never induce premature labor in these cases. Among 52 cases of ovariotomy during pregnancy, the uterus was punctured six times; the mortality in the remaining 46 cases was 15 per cent. for the mothers, and 50 per cent. for the children. In 18 of the operations pregnancy was not suspected. Olshausen says that there is no indication for interference during preg nancy, when the tumor is evidently a simple cyst of slow growth and not attended by much disturbance. A rapidly-growing cyst, which threatens to rupture, should be removed at once, unless it is firmly adherent, when it should be punctured. The pregnancy ought not to be interrupted ex cept in those rare cases in which ovariotomy is impossible, puncture im practicable, and in which the irreducible tumor becomes a serious obsta cle to delivery, that is in almost all cases of irreducible solid and dermoid cysts, located in the true pelvis.