Acute Obstruction of the Bowels. By DR. RYAx. 113

ART. VI. - -Acute Obstruction of t]~e Bowels in a Patient with Cystic Disease of t]~e Ovary; Tapping tI~e Cyst; Recovery. By RICHARD RYAX, M.D., Q.U.I. ; Medical Officer, Bailieborough Workhouse.

Ix T]ze Dublin Journal of Medical Science for June is recorded a case of cystic disease of the ovary causing acute obstruction of the bowels and death, the diagnosis having been verified post mortem. The case I am about to lay before your readers is in many points similar, and I have no doubt the details will prove interesting and instructive.

Mrs. A., aged thirty years, sallow, anmmic complexion, married eighteen months, consulted me for the first time on the 19th of January in the present year. About three years and a half since she remarked, and her mother also noticed, that her abdomen was rather large, but as the menstrual function was normal, medical advice was not sought. Her general health at the time was good, but she had repeated attacks of hmmorrhage from the rectum. On the 24th December, 1875, ten months after her marriage, she gave birth to an eight months' child, which survived only twelve days. She attributes her premature labour to fright, but probably the ovarian cyst had some influence thereon. Since then her health, appetite, &c., have been good.

On examination her pulse was 72, tongue clean, good digestion, but bowels usually constipated for years. In the horizontal position the abdominal enlargement was well marked. Fluctuation all over abdomen in front, with dulness on percussion. The fluc- tuation was propagated equally in all directions, indicating the absence of septa, whilst the distinctness and sharpness of the undulatory wave, elicited by the slightest touch, bore evidence to the thinness of the contained fluid. The lumbar regions of both sides were resonant. The abdominal dulness was indistinctly trace- able into the left iliae region; the right iliac region was resonant. She felt so well at the time--four weeks after her confinement-- that it was with some difficulty I could persuade her that the enlargement was not "natural to her," and the result of disease.

The diagnosis made was cystic disease of the ovary, probably unilocular, and growing from the left side.

I put her on aloetic pills and iodide of potassium, and saw her again in a fortnight. The health and physical signs remained

114 Acute Obstruction of the Bowels.

unaltered, so I recommended her to consult Dr. Kidd, of Dublin. He confirmed the diagnosis, and as her health was good and the tumour not appreciably growing, he did not recommend opera- tion, though considering the case a peculiarly favourable one for ovariotomy. With little hope of benefit he advised a trial of decoction of broom and jalap powder. After four or five weeks of this treatment there was no alteration in her bulk. She was then attacked with severe pain in the left ilio-lumbar region, followed by vomiting and retching, and a most painful feeling of distension. Fortunately, a dose of oil which she took produced a free discharge from her bowels, the pain and retching gradually subsided, and she was as well as ever in thirty-six hours. For some weeks after this she had gastric uneasiness and occasional vomiting, though her general health did not seem to suffer up to the date of the attack which I am about to describe.

April 30th.--She took a rather long walk and felt very well, but after going to bed she was attacked with very severe pain in the left side, accompanied with vomiting same as previously. For this she took another dose of oil, but the stomach rejected it. Next day the nearest medical gentleman saw her and ordered aperient draughts, which she vomited, and leeches, which tempo- rarily diminished the pain ; also three injections per anum, only the first of which produced a slight evacuation, and that from the lower bowel.

May 3rd.---I saw her in consultation for the first time during the present attack. She had been getting progressively worse, her condition being as follows :--Dorsal deeubitus; legs drawn up; extremities cold; anxiously painful expression of face; pulse 110, small, hard; temperature 100 ~ F. ; tongue clean; vomiting every- thing; respiration hurried, and superior costal. Her abdomen appeared much larger than when I had seen her three months before. Pain and tenderness confined to left side of abdomen. Cannot make any attempt to stir on account of the pain it pro- duces. Track of the descending colon resonant and prominent. No flatus passing per anum. Urine natural in appearance and quantity. I considered it a case of acute obstruction of the bowels, with probably local peritonitis following. Having regard to the extreme urgency of the symptoms, and expecting no benefit from medicinal means only, I proposed to tap the ovarian cyst with the hope of relieving the gut from the direct pressure of the tumour, or of so Mtering the relative positions of the gut and

By DR. I~u 115

the tumour as to enable the former to pass its contents onward. As my con/r}re was afraid that the operation, might increase the peritonitis, we laid the case fairly before the patient and her friends. They decided to have her submit to the operation, herself remarking that "she could not live, as if something was not done she would burst." We tapped with the ordinary abdominal trocar, and in the mesian line between the umbilicus and pubis. The fluid, which was thin, pale, straw-coloured, and transparent, measured about eight pints. She expressed herself relieved by the operation, and could turn on her side for the first time. The fulness of the abdomen did not quite disappear. Ordered two grains of calomel and half a grain of opium every four hours. An ounce of castor oil and half an ounce of turpentine, in a plnt of thin gruel, to be injected in four hours, and repeated twelve hours afterwards, if necessary. Ice, soda-water and sweet milk, and whey fbr thirst. To try a little corn flour twelve hours after the operation.

May 4th.--Pulse 112 ; temperature 100�89 ~ ; tongue clean ; gums just appreciably touched; slept a little after operation yesterday; retained the corn-flour; had a little vomiting after each pill, but the pills were not rejected; pain not so bad; countenance less anxious; abdomen soft and less tender; transverse colon promi- nent, resonant, and tender. The injections were returned unchanged after some hours. No flatus passed per anum; urine normal. I tried to pass the long tube, but could not get it beyond the rectum. Repeated the injection same as before, and hand rubbed for twenty minutes over the abdomen. Ordered to continue pills; to repeat the injection in twelve hours if required, and to take a castor-oil draught on the morning of the fifth. Warm linseed-meal poul. rices to abdomen renewed every six hours.

May 5th.---Pulse 115 ; temperature 101 ~ ; gums slightly touched ; tongue a little furred. Has taken eleven pills. Slept tbur hours last night. Had a severe attack of retching, lasting six minutes,

o n my arrival. "Thought something freed inside," after my departure yesterday. Subsequently passed some foul-smelling matter, but only sufficient to colour the injection which had been given previously. Transverse colon prominent, resonant, and tender. No flatus passing. Vomited castor-oil draught. Her change came on last night, being twenty days since the preceding one. In other respects the same as yesterday. Introduced about twelve inches of the long tube, affording exit to a quantity

116 Acute Obstruction of the Bowels.

of flatus, which gave her much relief, and pulse fell to 105. I then gave an injection consisting of six drachms of tartaric acid, and an ounce of the bi-carbonate of soda, each dissolved in a pint of cold water, and thrown up successively by means of a pint syringe. This was retained. Ordered to continue the pills, but with only half the quantity of opium, as she seems well under its influence, and a soap and water injection in twelve hours, if required.

May r not see her to-day, as I got a telegram stating that her bowels acted.

May 7th.--About four hours after my last visit her bowels moved freely; and, in the succeeding twenty-four hours, she had several evacuations, one of which was particularly offensive. There was a trace of blood in one of the stools. After that she slept well; but yesterday and last night she suffered from tenesmus, with very slight mucous stool, and this morning she felt very hot and sick. Pulse 104, full, soft, and bounding; temperature 100~ tongue furred; abdomen soft and sore, rather than tender. Prominence and tenderness of transverse colon have disappeared. Frequent yawning and rifting with acid eructations. No vomiting since last visit. Ordered an opiate, to relieve the tenesmus, and an alkaline aromatic mixture with bismuth. To continue warm poultices; five grains of rhubarb and five of blue pill to be taken at bedtime. From this date she improved steadily, and was able to walk about her room on the 12th of May.

June 1st.--Mrs. A. drove five miles to see me to-day, and walked five miles yesterday with little fatigue. She looks in good health, and does not appear any larger in the abdomen than when I first saw her on the 19th of last January. She suffers from flatulence and troublesome eructations. Has to take aperient pills regularly. As she looks a little anaemic, I have put her on five-grain doses of the citrate of iron and quinine, three times a day.

Remarks on the Case.--The diagnosis lay between local perito- nitis and acute obstruction. To the latter opinion I inclined, and directed both the medical treatment and the operative interference to its relief. The tap wound healed very kindly, and she never complained of any pain at or around it. Before introducing the trocar I ascertained by percussion and palpation the absence of any intervening coil of intestine at the point of intended puncture, and by firm pressure from that time until I withdrew the canula, when the fluid ceased to flow, I prevented the point of the eanula and

By DR. RrA~. 117

the cyst fluid from escaping into the peritoneal cavity as the cyst wall collapsed.

Chronic constipation is one of the most frequent results of ovarian tumour; but acute obstruction of the bowels is a very rare complication, if one may judge by the number of recorded cases in the medical journals and the silence regarding it observed in the principal class books on the diseases peculiar to women. To the ordinary medical mind it is a little surprising that the presence of a tumour Hlarge and often enormous size should not more frequently give rise to acute obstruction, and paticularly when it so frequently produces chronic constipation. Can it be that in many cases of ovarian cyst, in which the patient's illness, or even death, is attri- buted to peritonitis, the peritonitis which has only supervened before the arrival of the doctor, is really the effect of acute obstruc- tion and strangulation of the bowels ? I believe it is not improbable. In all the cases of tapping that I have seen recorded the operation has been performed with the view of curing or palliating the ovarian disease, or of relieving pain, dyspncea, or some urgent symptom other than acute obstruction. The statistics of tapping in ovarian dropsy show a mortality of one in five. So high a rate can only be accounted for by performing the operation when the patient is almost dying, or in unsuitable cases, such as multilocular cysts, or cysts with Solid contents, otherwise the death-rate is inconceivably high compared with that H tapping in ascites. Hence, the death- rate ought not to deter us in such a case as I have here recorded. The co-existence of pregnancy with ovarian cyst, though unusual, is not very rare, and several cases in which mother and child got well at the usual time for delivery, are on record; but the more common termination, as in my case, is premature labour.

Four considerations point to the lower part of the colon, probably its sigmold flexure, as the seat of obstruction, viz. : - -

1. The urine being in fair quantity. 2. The escape of flatus for the first time when I succeeded in

passing the long tube about twelve inches. 3. The fixed pain and tenderness in the left iliac region; and 4. The marked distension of the transverse and descending colon.

Three reasons induced me to attribute the acute obstruction to the ovarian cyst : - -

1. The liability of such a large body to interfere with the natural movements of the intestines.

118 Acute Obstruction of the Bowels.

2. T h e seat of the obs t ruc t ion be ing t ha t pa r t of the in t e s t ina l t rac t which, from i ts re la t ion on the one side to t he pedic le and leas t movable par t of the ovar ian cyst , and on the e t h e r to t h e pe lv ic and uny ie ld ing pa r t o f the abdomina l par ie tes , was spec ia l ly exposed to pressure and counter -pressure .

3. T h e immedia te sense of re l ie f and subsequent comple t e r ecove ry af ter the operat ion.

B L I N D N E S S F R O M W H O O P I N G - C O U G H .

KNAPP (~ Archives of Ophthalmology and Otology," IV. 3 and 4) reports the case i - - A boy~ three years old, had suffered from whooping-cough six weeks; was emaciated and excitable. For two days the parents had observed loss of sight~ and he had complained of darkness, though his condition otherwise had not changed. Knapp found no abnormity exter- nally~ and the pupils responded to light, but the boy could not even tell the direction of the window. Wi th the ophthalmoscope marked retinal ischmmia was observed; the nerve-discs were white r the veins scant and thin ; in one eye only the main branches of the arteries to be seen as fine threads, in the other no arteries visible. As no change was evident after twenty-four hours of nutritious d i e t and stimulants~ paraeentesis of the anterior chamber was performed, in order to diminish the intra-ocular prcssure~ and so favour tho entrance of blood to the eye. The next day the retinal vessels were better filled, and the optic discs less white ; the boy could also point out the window. The condition of the retina and discs improved gradually~ and the patient became able to recognise objects about him, but vision never reached the normal standard. The general disease did not improve~ however~ and death ensued~ six weeks later~ from lobular pneumonia. Blindness from whooplng-ceu~h is veryrare . Knapp quotes Professor Loomis to the effect that it has been observed almost exclusively in children who have died from lobular pneumonia~ and as this was also the result in the present case, the symptom would appear to be a very grave one. The question as to the causation of ~schmmia retinm generally is still undecided~ and this case does not offer a solution. Knapp was inclined to refer the isch~emia to the general anaemia and weak action of the heart, or possibly to a h~emorrhagic effusion between the sheaths of the optic nerves. The lat ter supposition derives some support from the frequent occurrence of eonjunctival hmmorrhages in whooping-cough. This frequency of conjunctival h~emorrhage would also lead us to infer intra-ocular h~emorrhages where disturbance of vision occurred, but in the case related nothing of the sort was observed. A point of interest in the case is the good influence which seems to have been exerted by the paracentesis.--,Bost. _Med. and Surg. Jour.