2. Cysts of the parovarium and of the broad ligament being often cured by the use of the trocar, it is proper to try the effect of one tapping in slow-growing, unilocular, thinned-walled, and flaccid cysts, which thus exhibit the chief characteristics of these extra-ovarian cysts.
3. When an ovarian cyst develops during the later months of pregnancy, it will often be best to resort to tapping in order to relieve the woman from the pressure of two growing organs and enable her to go to full term. Sometimes labor is made impossible by the presence of a cyst, which will then have to be emptied.
4. In very large tumors which by pressure interfere with the functions of the kidneys, heart, and lungs, thereby causing albuminuria, oedema, or dyspnoea, tapping is a useful prelude to ovariotomy. By the relief from pressure afforded to these organs not only will the liability to shock be lessened, but also to hemorrhage, for vessels previously varicose will now contract to their natural calibre.
5. In cases of doubtful diagnosis or in those in which from malignancy, from formidable adhesions, or from other circumstances the radical operation is deemed impracticable, tapping in the first case may clear up the diagnosis, and in the latter ones will prolong the patient's life. But it must always be borne in mind that in a few weeks the fluid will reaccumulate, and the operation will have to be repeated, rapidly exhausting the patient by the drain on her system. It is well, therefore, to put off the first tapping as long as possible.
28 American Journal of Obstetrics, Nov., 1883, pp. 1169 and 1189; also Transactions American Gynæcological Society, vol. ii., 1877, p. 270.
29 Midland Medical Society, Lancet, Feb. 18, 1882.
Tapping may be performed through the abdominal wall, through the vagina, or through the rectum, but, for reasons which will presently be given, the first mode is decidedly the best.
Tapping through the Abdominal Wall.—For this operation either the aspirator may be used or else Wells's trocar with a long rubber tube attachment. Of the two, I much prefer the former. In aspiration, after the bladder has been emptied, the woman lies on her back close to the side of the bedstead with her abdomen exposed. The preferable site of puncture is in the linea alba midway between the navel and the symphysis pubis; that is to say, at a point where the tissues, being tendinous, are most free from blood-vessels, and where the omentum is most out of the way. But if at this point the tumor feels solid, or an underlying knuckle of intestine is discovered by percussion, or the vessels look varicose, any other place in the abdominal wall may be selected where fluctuation is most manifest, provided it lies below the level of the navel. The reason for choosing a low site for the puncture is, that if the hollow needle be plunged in at any point above the navel it will slip out of the cyst as the latter collapses and before it is wholly emptied. The skin is now thoroughly cleansed with soap and water and washed with a 5 per cent. solution of carbolic acid. The painful part of the operation being the penetration of the skin, the selected place for puncture should either be frozen with the ether spray or be benumbed by a lump of ice dipped into some table-salt. After the aspirator-jar has been exhausted of air the hollow needle or canula, armed with its stilette, is lubricated with carbolated oil or vaseline, and rapidly plunged deeply into the cyst. Should the cyst not wholly collapse, the canula has probably become obstructed, and it should be cleared out by one of the blunt stilettes which are made of different sizes to fit the different canulas. Sometimes the flaccid walls of the sac as it becomes empty are sucked up into the end of the canula, and the flow of fluid is suddenly arrested. This accident is recognized by a peculiar valve-like vibration communicated to the instrument, and is overcome by raising up the end of the canula or by directing it to another part of the cyst. Should, on the other hand, other cysts present themselves, they can be emptied without withdrawing the canula by reintroducing the stilette, and by directing its point to each cyst in succession. When the fluid ceases to flow the fore finger and thumb firmly compress the fold of the abdominal wall behind the canula as it is withdrawn, so as to avoid the entrance of air, and the small puncture is covered by a piece of adhesive plaster. A pad of cotton wool is now laid over the scaphoid abdomen and a flannel binder applied. These afford a grateful feeling of support and take away that sense of goneness which is likely to occur. To avoid all risks of inflammation the patient must keep her bed for three or four days and eat sparingly.
When Wells's or any other large trocar is used, the operation should be performed under the spray and with every antiseptic precaution. The skin should be previously incised with a lancet, and, lest air should be sucked up into the sac, the free end of the rubber tubing should touch the bottom of the bucket, so as to be always immersed in the escaping fluid. This rubber tubing acts as a syphon with great suction power, and the cyst is more rapidly emptied by Wells's trocar than by the aspirator. Yet I cannot help believing that the latter by its small size is by far the safer instrument, and I always use it when a simple tapping is aimed at. Should any stubborn bleeding follow the removal of the canula, a harelip pin may be passed across the wound deeply enough to get below the wounded vessel, and compression made by a turn or two of silk ligature around the pin. The same means are to be adopted to stop the oozing of fluid which sometimes takes place when a cyst with colloid contents cannot be wholly emptied by the trocar. For it is highly prudent under such circumstances to stop the oozing, as some of the fluid is sure to get into the cavity of the peritoneum, with very generally fatal effects. In such a case the pin ought to include the lips of the wound in the cyst. To avoid as much as possible the escape of irritating ovarian fluid into the cavity of the abdomen, the cyst when tapped should always, if possible, be wholly emptied. This is a rule without an exception. It is therefore very bad practice to remove even with the hypodermic syringe a few drops of the fluid for microscopic examination. Several cases of death from this cause have been reported.30 I lay stress on this point because in my Lessons in Gynæcology I advocate the practice.
30 American Journal of Obstetrics, April, 1876, p. 146.