Fig. 169.—Double papillomatous cyst of the ovary. The right cyst has ruptured and is turned inside out, showing a mass of papillomata. Papillomata have penetrated the wall of the left cyst. The peritoneum has been infected, and a papillomatous growth appears on the fundus uteri.
Fig. 169.—Double papillomatous cyst of the ovary. The right cyst has ruptured and is turned inside out, showing a mass of papillomata. Papillomata have penetrated the wall of the left cyst. The peritoneum has been infected, and a papillomatous growth appears on the fundus uteri.
The escape of a small quantity of the cyst-fluid into the abdomen during the removal of the tumor may cause subsequent recurrence in the peritoneum. Secondary development of the growth in the abdominal cicatrix, or its appearance in the site of puncture after tapping, is due to the same cause.
Papillomata of the peritoneum are usually accompanied by ascites. This is a prominent symptom in those cases of papillomatous ovarian cyst in which secondary infection of the peritoneum has taken place. In rare casesascites is present, though perforation of the cyst and involvement of the peritoneum cannot be detected.
Sometimes perforation of the cyst takes place into adjacent organs, especially if the growth be intra-ligamentous. In such cases the papillomatous masses may protrude into the bladder, the rectum, or the cavity of the uterus.
The parovarium consists of a series of fine tubules lying between the layers of the mesosalpinx. It may be seen in the fresh specimen by holding the mesosalpinx stretched between the eye and the light (Fig. 145).
The typical parovarium consists of three parts: a series of vertical tubules; a series of outer tubules free at one extremity; and a larger longitudinal tubule.
The vertical tubules range from five to twenty-four in number. They converge somewhat toward the ovary, where they end in blind extremities and become closely associated with the paroöphoron. At the other end they terminate in the larger longitudinal tubule.
The series of outer tubules are called Kobelt’s tubes. They are free and closed at the distal extremity, while at the proximal extremity they join the longitudinal tubule. The larger longitudinal tubule is called the duct of Gärtner. It may sometimes be traced traversing the broad ligament to the uterus, and through the walls of this organ and of the vagina to its termination at the urethra. It corresponds to the vas deferens in the male. When persistent in the vaginal wall it may become the starting-point of a vaginal cyst.
The vertical tubes of the parovarium are from 0.3 to 0.5 millimeters in diameter. They are occasionally found lined with ciliated columnar epithelium. Usually they contain a granular detritus representing the remains of broken-down epithelium.
Cysts may arise from any of the parts of the parovarium.
Kobelt’s tubes frequently become distended, and formsmall pedunculated cysts about the size of a pea. They are of no clinical importance (Fig. 145). They are often observed in operations for ovarian disease, and are very often mistaken for the hydatid or the cyst of Morgagni which springs from the Fallopian tube, and which has already been described.
Fig. 170.—Cyst of the parovarium. There is no distortion of the ovary. The Fallopian tube has been much elongated.
Fig. 170.—Cyst of the parovarium. There is no distortion of the ovary. The Fallopian tube has been much elongated.
The difference between these two varieties of small cysts may be determined by careful examination of the point of origin and by means of the microscope. Sutton states that the cyst of Morgagni has muscular walls and is lined by ciliated columnar epithelium. In the cyst of Kobelt’s tubes the walls are fibrous and the lining is cubical epithelium.
Large cysts of the parovarium originate from the verticalor the longitudinal tubules, and usually remain sessile and develop between the layers of the mesosalpinx and the broad ligament. As the cyst grows and separates the layers of the mesosalpinx, it comes into close relationship with the Fallopian tube. This structure, being held by its uterine connection and the tubo-ovarian ligament, becomes stretched across the surface of the cyst and very much elongated. The elongation of the Fallopian tube is a very constant accompaniment of parovarian cysts. The tube may attain a length of 15 or 20 inches. The fimbriæ may also become much stretched and elongated by the traction of the growing cyst, and may attain a length of 4 inches.
The ovary is unaffected unless the cyst be of very large size, in which case the ovary may be stretched upon the surface of the cyst, so that its position becomes difficult to determine.
There are two varieties of parovarian cyst—the simple and the papillomatous.
Thesimple parovarian cysthas a very thin wall of uniform thickness. In small cysts, less than the size of a child’s head, the wall may be transparent. It is of a light yellowish or greenish color, and the fine vessels ramifying upon the surface are plainly visible. As one would expect from the direction of growth, the outer covering of the cyst is peritoneum, which is not adherent and may be readily stripped off. The middle coat is composed of fibrous tissue containing unstriped muscle. The lining membrane is ciliated columnar epithelium, stratified epithelium, or simple fibrous tissue, according to the size of the cyst. The changes in the character of the epithelium are due to pressure. The cyst-contents are a clear, limpid, opalescent fluid of a specific gravity below 1010.
In thepapillomatous parovarian cystthe interior is covered with warts or papillomatous growths resembling in every respect those that occur in the cyst of the paroöphoron, already described. The papillomatous parovariancyst exhibits the same clinical features, and is liable to the same accidents, as the paroöphoritic cyst. It may become perforated and infect the general peritoneum.
The walls of the papillomatous parovarian cyst are somewhat thicker than those of the simple parovarian cyst; the fluid contents are not so clear and limpid, and may contain altered blood that has escaped from the papillomata.
Parovarian cysts are almost invariably unilocular. Only a few cases have been reported in which two or more cavities were present.
The cysts are of small size, not often exceeding that of a child’s head. They may, however, attain large dimensions and contain several quarts of fluid.
Parovarian cysts are of very slow growth, and refill but slowly after tapping or rupture. On account of the thinness of the cyst-walls, these cysts seem especially liable to the accident of rupture. Unless the cyst be papillomatous, the bland, unirritating fluid is readily absorbed by the peritoneum, and the cyst may remain quiescent for a long period.
Cysts of the parovarium occur most frequently during the period of active sexual life. Unlike dermoids and cysts of the oöphoron, they are unknown in childhood.
Cysts of the parovarium are much less common than cysts of the oöphoron and paroöphoron. In 284 tumors of the ovary and parovarium operated upon by Olshausen, about 11 per cent. originated in the parovarium.
Some authorities maintain that in rare instances dermoid cysts may arise from the parovarium.
The symptoms of parovarian cysts resemble those of ovarian cysts of similar development. On account of the intra-ligamentous development of the tumor, pressure-symptoms may appear early. The cyst is of such slow growth that the simple parovarian cyst may exist for a long time without giving any trouble whatever. The slow growth is the only clinical feature that would enable one to make a diagnosis between parovarian and ovarian cyst.
The chief characteristic features of the large cysts of the. ovary and the parovarium—the glandular cyst, the paroöphoritic cyst, and the parovarian cyst—may be tabulated for comparison as follows:
Fig. 171.—Section, perpendicular to the long axis of the Fallopian tube, passing through the tube, the parovarium, and the ovary; showing the relation of the structures to the peritoneum of the broad ligament.
Fig. 172.—Section, perpendicular to the long axis of the Fallopian tube, showing the relation of an oöphoritic cyst to the peritoneum of the broad ligament.
Fig. 173.—Section, perpendicular to the long axis of the Fallopian tube, showing the relation of a paroöphoritic cyst to the oöphoron and the peritoneum of the broad ligament.
Fig. 173.—Section, perpendicular to the long axis of the Fallopian tube, showing the relation of a paroöphoritic cyst to the oöphoron and the peritoneum of the broad ligament.
Glandular Oöphoritic Cyst.—Intra-peritoneal in development;no peritoneal investment. Ovary destroyed early in the course of the disease. Cyst multilocular.
Fluid contents thick, colored; specific gravity greater than 1010.
Tumor of rapid growth.
Usually unilateral.
Fallopian tube distinct from tumor, and not much, if any, elongated.
Paroöphoritic Cyst.—Often extra-peritoneal in development, in which case there is a detachable peritoneal investment.
Oöphoron not at first involved by the growth.
Unilocular.
Fluid contents less thick and viscid than in oöphoritic cyst.
Interior filled with papillomata.
Tumor usually of slower growth than the oöphoritic cyst.
Very often bilateral.
Fallopian tube more likely to be involved than in oöphoritic cyst.
Fig. 174.—Section, perpendicular to the long axis of the Fallopian tube, showing the relation of a parovarian cyst to the ovary, the tube, and the peritoneum of the broad ligament.
Fig. 174.—Section, perpendicular to the long axis of the Fallopian tube, showing the relation of a parovarian cyst to the ovary, the tube, and the peritoneum of the broad ligament.
Cysts of the Parovarium.—Intra-ligamentous in development. Peritoneal investment which may be stripped off.
Ovary pushed aside, but shape not affected unless the cyst be very large.
Cyst unilocular.
Wall thin. Fluid contents watery, opalescent; specific gravity below 1010.
May or may not have papillomata in interior.
Tumor of very slow growth.
Usually unilateral.
Fallopian tube much elongated and stretched immediately over the surface of the cyst.
In the discussion of the secondary changes, the clinical history, and the treatment of cysts, the oöphoritic, paroöphoritic, and parovarian cysts will be considered together under the general heading of ovarian cysts.
There are various accidents which may happen to an ovarian cyst which have an important bearing on the clinical course of the disease. These accidents are: inflammation and suppuration; torsion of the pedicle; rupture of the cyst.
Inflammation and Suppuration.—Inflammation of an ovarian cyst is of very common occurrence. It seems especially liable to happen in the small cysts of pelvic growth. Ovarian dermoids are very often inflamed. The inflammation may result in but a few peritoneal adhesions between the outer surface of the cyst and some of the contiguous structures, as a loop of intestine, the bladder, the anterior abdominal wall, the omentum, etc., or the whole cyst may be universally adherent, so that its removal is rendered most difficult, and in some cases impossible.
The operator should always remember the possibility of these adhesions in removing an ovarian cyst. Its surface should be carefully examined as it is dragged slowly through the abdominal incision, in order that slight adhesions to delicate structures like the omentum and the vermiform appendix may not be recklessly or unknowingly torn.
The sources of inflammatory infection of an ovarian cyst are the intestinal tract, the urinary bladder, and the Fallopian tube. Perhaps salpingitis is the most frequent cause of such inflammation. Infection often comes from the vermiform appendix, which is frequently found adherent to the surface of the tumor.
Old adhesions usually contain blood-vessels, which may be of large size, especially if they arise from the intestine, the omentum, or the uterus. In some cases in which the tumor has become detached from the pedicle by rotation or traction the adhesions have been sufficiently vascular to maintain the vitality of the tumor.
Suppuration of ovarian cysts is sometimes seen. It was more frequent in the period when these tumors were treated by tapping, as infection occurred in this way.
Suppuration is most common in ovarian dermoids. The tumor may become adherent to surrounding structures, and may discharge its contents through the bladder, the vagina, the rectum, or the abdominal wall. A tooth thus discharged into the bladder from a suppurating dermoid has in several instances formed the nucleus of a vesical calculus.
A suppurating ovarian cyst sometimes contains gas, either from communication with the intestine or from decomposition of its contents. In such a case the usual tumor-dulness is replaced by a tympanitic note.
Torsion of the Pedicle, or Axial Rotation.—Ovarian tumors occasionally rotate upon their axes, so that the structures that form the pedicle become twisted. The severity of the symptoms that arise from this accident depends upon the degree of compression to which the vessels of the pedicle are subjected from the torsion.
The accident is not now as common as formerly, because the tumor is, as a rule, now removed as soon as it is recognized, and many of the accidents that were described as very frequent by the older writers are avoided. The many recorded cases—chiefly of a date before our present surgical era—show that axial rotation occurred inabout 10 per cent. of the cases of ovarian and parovarian tumors. Rokitansky found torsion of the pedicle in 12 per cent. of all cases of ovarian tumors, and in 6 per cent. of the cases it was the cause of death.
The cause of axial rotation is unknown. It has been attributed to alternate distention and evacuation of the bladder, to the passage of feces through the rectum, and to a sudden jar or motion of the body.
The accident is especially likely to occur when an ovarian cyst complicates pregnancy or when both ovaries are cystic. Torsion of both pedicles has been found in women suffering with bilateral ovarian cysts.
Torsion of the pedicle is more apt to occur in cysts of medium and small size than in the large tumors.
Torsion of the pedicle affects equally tumors of the right and left sides. The direction of rotation is usually toward the median line, though it may take place in the reverse direction.
There is considerable variation in the amount of rotation. In some cases the pedicle has twisted through but half a circle, while in others twelve complete twists have been found. A pedicle twisted in this way resembles a rope. Such a high degree of torsion is the result of a slow or chronic process. The rotation of the tumor takes place so gradually, or the arrangement of the blood-vessels in the pedicle is such, that no appreciable effect upon the tumor is produced, and no symptoms arise from it. The operator frequently meets examples of such slow torsion in removing ovarian tumors. In extreme cases the twisting progresses until the blood-supply through the pedicle is arrested, and the cyst may become freed from its peduncular attachment. If adhesions had formed to the cyst-wall, the vitality may be maintained through these channels; the tumor, in fact, becomes transplanted. This phenomenon is most frequent with dermoids.
Very different are the phenomena of acute torsion. Here the vascular supply of the tumor is so suddenly and markedly interfered with that most urgent symptomsimmediately arise. The interference with the circulation depends upon the amount of the twist and the character of the pedicle. The effect is first felt by the veins, which are more compressible than the arteries; the venous blood-current becomes obstructed, while the arteries remain open. Venous engorgement of the cyst results; extravasation of blood takes place in the walls, or the veins may rupture and hemorrhage may take place into the cyst-cavity. Death from acute anemia may result from this cause. Thrombosis and necrosis of the tumor may occur as a result of acute torsion.
Rupture of Ovarian Cysts.—Rupture of an ovarian cyst is an accident of not infrequent occurrence. It is probable that small cysts rupture and refill without the attention of the woman or the physician being directed to the accident. The scars of old ruptures are frequently found on the surface of ovarian cysts. Wells found rupture of the cyst 24 times in a series of 300 ovariotomies.
There are various causes which predispose to rupture or lead to it. As the cyst enlarges, the walls become very thin as a result of the distention. The cyst-wall may undergo, in places, retrograde changes—atrophy and fatty degeneration. The wall may become weakened as a result of suppuration, thrombosis, and the results of torsion of the pedicle; and, as has already been said, papillomatous growths destroy the integrity of the wall and lead to perforation.
The immediate cause of the rupture is usually a sudden jar or a fall. Sometimes very slight pressure is enough to rupture the cyst. The manipulations of a physician, turning in bed, and coughing have caused this accident.
The effects of rupture depend upon the character of the cyst-contents.
Hemorrhage may be profuse and rarely fatal. The hemorrhage, however, is usually not severe, because the rupture takes place in the attenuated part of the cyst, which is but poorly supplied with blood-vessels.
If the fluid is unirritating to the peritoneum and contains but little solid material, it is often readily absorbed by the peritoneum and passed off by the kidneys. Large quantities of fluid may be absorbed and eliminated in this way. A case has been reported in which the rupture of a cyst was followed by profuse diuresis which lasted four days, during which time 65 pints of urine were discharged.
Another case has been reported in which the cyst ruptured and refilled 34 times during a period of nine years. The fluid on each occasion was absorbed by the peritoneum and discharged by the kidneys without in any way incapacitating the woman.
If the cyst-contents are septic, as is often the case in dermoid cysts, fatal peritonitis will result. The danger of rupture of the papillomatous tumors—general papillomatous infection of the peritoneum—has already been described.
Similar infection may rarely occur from the escape into the peritoneum of the colloid contents of a ruptured glandular cyst. After such an accident the peritoneum has been found covered with tough gelatinous masses, of a gray or yellow color, which reached the size of a hickory-nut. This condition has been calledmyxoma peritonæi.
Very rare cases of similar metastasis from rupture of dermoid cysts have been reported. In one case yellow nodules the size of a pea, containing light-colored hair, were found scattered upon the peritoneum.
It is probable that when the walls of an ovarian cyst are very thin, slow transudation of the fluid into the peritoneum takes place.
The symptoms produced by ovarian cysts depend upon their size, their position, and the accidents that may arise. If the tumor be intra-peritoneal in its development, the woman’s attention is usually first directed to the pathologicalcondition when the growth has attained sufficient size to extend above the pelvis. The time of the perception of the tumor depends upon the intelligence and powers of observation of the woman and the thickness of the abdominal wall. A cyst often attains a large size and reaches well up into the abdomen before the woman is aware of its existence. In the papillomatous cysts sometimes the first symptoms that attract the woman’s attention appear after the cyst has become perforated and the peritoneum has become invaded by the papillomata.
Pain, except that due to pressure or inflammation or some other accident, is not at all characteristic of ovarian cysts.
If the cyst be intra-ligamentous in development, or if it be wedged in the pelvis, the first symptoms of the disease appear at an earlier date. The intra-ligamentous tumors first separate the layers of the broad ligament; they push the uterus to one side, and press upon the bladder, ureters, and rectum. The disposition of the peritoneum may be altered in a variety of ways by these growths. They may grow altogether behind this membrane, becoming retro-peritoneal, coming into immediate relationship with the rectum; or they may pass behind the cecum and the ascending colon, growing between the layers of the mesocolon. They sometimes develop more especially under the anterior layer of the broad ligament, strip off the peritoneal covering of the bladder, and come into immediate relationship with the anterior abdominal wall; so that if laparotomy is performed, the operator will enter the cavity of the cyst before he has opened the general peritoneum. It is of the greatest importance that the surgeon should be familiar with such unusual ways of development of these tumors, as the operative difficulties that are encountered are most embarrassing.
Pressure upon the ureters occurs not only in the cysts of intra-ligamentous growth, but also in the large-sized intra-peritoneal tumors. It is a frequent complication,and the hydronephrosis and kidney-degeneration that result may be the immediate cause of death.
Doran says that in 32 cases out of 40 autopsies on women with large ovarian tumors, kidney disease, probably caused by pressure of the tumors, was present. The writer has found a ureter distended to an inch in diameter from pressure of a papillomatous cyst. The pressure of the tumor sometimes produces edema of the lower extremities and of the anterior abdominal walls.
The presence of ascites with cysts of papillomatous nature has already been spoken of. Though this complication is especially characteristic of these tumors, and usually indicates peritoneal involvement, yet it is sometimes found with the glandular and the dermoid cysts. In these cases it is caused by the direct mechanical irritation of the peritoneum by the movable tumor. It accompanies also freely movable solid tumors of the ovary and pedunculated fibroids of the uterus.
Notwithstanding the gross disease of the ovaries, the functions of the uterus are in no way specifically affected by ovarian cysts. The uterus may be pushed to one side, pressed backward into the hollow of the sacrum or forward against the pubis, but menstruation may not be affected, and conception may take place even with tumors of very large size.
In some cases there is menorrhagia, or continuous bleeding, which appears with the appearance of the cyst and disappears after its removal. This phenomenon may occur in old women who have long passed the menopause, and may excite the suspicion of coincident malignant disease of the uterus. On the other hand, menstruation may be diminished or arrested.
Reflex disturbances in the breast may occur with ovarian cysts, as in any form of ovarian disease. The areola may become pigmented, the breasts swell, and a milky secretion may be produced even in young girls.
Malignant degeneration may occur in any form of ovarian cyst. It seems to be most frequent in the papillomatoustumors, next in the dermoids, and less frequent in the glandular cysts.
The rapidity of growth of ovarian cysts varies a great deal. The glandular tumors are of the most rapid development. They sometimes attain a very large size within a few months. The rate of accumulation of the fluid depends upon the intracystic pressure, and is consequently greatest immediately after rupture or tapping. Some remarkable cases of great rapidity of accumulation after tapping have been reported. In one case 90 pints of fluid reaccumulated in seven weeks—a rate of about 2 pints a day. In another case 3½ pints of fluid were accumulated every day.
The enormous size attained by ovarian cysts, and the tremendous amount of fluid drawn off from them, are shown by the old records of the days when tapping the cyst was the only treatment. A few references will illustrate this. In one case 1920 pints of fluid were drawn off by 66 tappings in a period of sixty-seven months. In another case 2787 pints were withdrawn by 49 tappings. In another case 9867 pounds were withdrawn by 299 tappings. The fluid in these remarkable cases must have been of low specific gravity, containing but little solid matter, or the women would have sooner succumbed from the drain on the system.
The misery of the women who were slowly crowded out of existence by these enormous tumors, or who, though with life prolonged by tapping, were exhausted by the continuous drain, was depicted in their countenances. The expression was called thefacies ovariana. We do not often see it at the present day. Wells describes it thus: “The emaciation, the prominent or almost uncovered muscles and bones, the expression of anxiety and suffering, the furrowed forehead, the sunken eyes, the open, sharply defined nostrils, the long, compressed lips, the depressed angles of the mouth, and the deep wrinkles curving around these angles, form together a face which is strikingly characteristic.”
The natural duration of life depends upon the character of the ovarian tumor. A dermoid may exist from childhood and give no trouble—in fact, may not be recognized until some accident starts it into rapid development. Even then it is of comparatively slow and limited growth, and danger from it is due to the accidents, such as inflammation and suppuration, to which it is especially liable.
Though the papillomatous cyst is also of slow growth when compared with the glandular cyst, yet the danger here is due to peritoneal infection, which very often takes place before the tumor has, by its size, begun to annoy the woman.
The glandular cyst, however, is of rapid, continuous, unlimited growth, and usually destroys the woman within a period of three years. Life has been prolonged for a much longer period in some cases by palliative treatment and tapping. On the other hand, life may at any time be cut short by the occurrence of some accident, such as rupture or torsion of the pedicle.
Symptoms of the Accidents that occur in Ovarian Cysts.—The symptoms of inflammation are pain and tenderness over the surface of the tumor. The tenderness is often limited to a local area which marks the position of an intestinal adhesion.
When suppuration takes place, the symptoms indicative of the presence of pus appear—elevated temperature, rapid and feeble pulse, exhaustion, and emaciation.
Symptoms of Torsion of the Pedicle.—There are no characteristic symptoms of slow or chronic torsion, unless, perhaps, retardation of the growth of the tumor appears as a result of the interference with the circulation.
The symptoms of acute torsion are, however, very marked. The woman is seized with sudden and violent pain in the abdomen, accompanied by vomiting and collapse. Sometimes the abdomen becomes rapidly increased in size on account of the venous engorgement of thetumor. If a woman known to have an ovarian tumor is thus attacked, the diagnosis of torsion of the pedicle may be made. The diagnosis is rendered more probable if the woman is also pregnant or if she has been recently delivered. If the woman presents herself for the first time to the physician with these acute symptoms, and he finds by abdominal and pelvic examination that there is an ovarian tumor, he should suspect that torsion of the pedicle has occurred.
Rupture of the Cyst.—Rupture of an ovarian cyst usually follows a fall, a violent attack of coughing, vomiting, etc.
The woman is seized with sudden pain in the abdomen, with perhaps symptoms of collapse and loss of blood.
The shape of the abdomen becomes quickly altered from that characteristic of encysted fluid to that characteristic of free fluid in the peritoneum. The alteration in shape is so marked that it may readily be perceived by the patient.
These phenomena are followed by profuse diuresis, or perhaps by symptoms of peritoneal inflammation.
If the woman survive, there is a gradual reaccumulation of fluid and a return of the abdomen to the former shape.
Examination.—In the early stages of an ovarian cyst, while it is in the pelvic state of development, bimanual examination will reveal the condition. The tumor lies to the side, to the front, or behind the uterus. The uterus may be moved independently of the tumor. The cystic character of the growth may often be determined by palpation; fluctuation may be felt between the vaginal finger and the abdominal hand. If the tumor be intra-peritoneal, with a pedicle, it will be found to be movable, and may be pushed out of the pelvis up into the lower abdomen. If it be intra-ligamentous, the range of motion is limited, the tumor is situated lower in the pelvis, and is in closer relationship with the uterus.
The shape of the tumor is usually spherical. In a multilocular cyst the surface may be lobulated; in a dermoidcyst the pultaceous character of the contents may sometimes be determined by pressure with the vaginal finger.
When the tumor has attained a sufficient size to have extended into the abdomen, much may be determined by careful abdominal examination. The woman should lie upon the back, and all constricting clothing should be removed. The whole abdomen should be exposed.
The bulging or prominence caused by the cyst is usually apparent in a thin woman. It commonly occupies the middle of the abdomen, but when not very large may lie to either side.
Palpation reveals the smooth, spherical character of the growth, or the lobulated surface from the presence of secondary cysts. Perhaps an area of marked tenderness may be discovered, which often shows the seat of peritoneal inflammation and adhesion. In the papillomatous tumors that have become perforated, irregular masses of papillary growths may sometimes be felt through the abdominal walls, situated either on the surface of the tumor or in some other portion of the abdomen. The association of such masses with a cystic tumor of the ovary and ascites renders the diagnosis of papillary cysts very certain.
If the tumor is non-adherent and of medium size, it may be moved from side to side or upward in the abdomen.
Fluctuation may often be elicited by palpation, and is most marked in the unilocular cysts with thin contents. If the contents be thick, as in many of the glandular cysts, or if the cyst be multilocular, fluctuation may not be obtained. The wave of fluctuation is interfered with by intervening septa.
Percussion reveals a central area of flatness which marks the most prominent part of the tumor. Intestinal resonance may be obtained above and to the sides of the cyst, and in some cases below it. In instances of this kind a central area of flatness is found surrounded by a ring of resonance.
This phenomenon is very different from that which appears if the fluid accumulation is free in the peritoneum. In the latter case the fluid gravitates to the flanks when the woman is upon her back, and the intestines float to the front, so that there is a central area of resonance, with dulness to the sides. In the very unusual cases in which gas is contained in the cyst-cavity the area of flatness will be replaced by an area of a tympanitic note.
If the woman sits up or lies on either side, the relation between the areas of flatness and resonance is unaltered in the case of an ovarian cyst, while, as is well known, if the fluid be free it will gravitate to the most dependent portion of the abdomen.
Auscultation reveals nothing of importance in regard to ovarian tumors. It is of value in enabling one to make a differential diagnosis between an ovarian tumor and pregnancy.
Vaginal examination in the case of a large tumor shows the character and the position of the lower portion of the growth, and sometimes enables the physician to determine upon which side the tumor had started. In ruptured papillomatous cysts the papillary masses may sometimes be felt behind the uterus when they cannot be detected by the abdominal hand.
The details of the natural history and pathological features already given will often enable the physician to make a differential diagnosis among the different kinds of ovarian cysts. Such a differential diagnosis, however, is of no importance whatever, as all such tumors require similar operative treatment.
To discuss the subject of the differential diagnosis of ovarian cysts from other pelvic and abdominal tumors would require a consideration of all the pathological growths that may occur in the abdomen. About every form of abdominal tumor has been mistaken for ovarian cyst. Differential diagnosis is here also of but little importance at the present day if the examiner is able toexclude pregnancy, phantom tumor, and fat. Operation is indicated in practically all morbid growths of the abdomen, with the exception of inoperable malignant disease; no surgeon should undertake any abdominal operation unless he is prepared to deal with any condition that may be found.
The difficulty of making a differential diagnosis is well illustrated by many cases that have been recorded, in which it was impossible to determine the true nature of the tumor even after the abdomen had been opened.
It is of the greatest importance to exclude pregnancy. Many women have been subjected to the operation of celiotomy because the pregnant uterus was mistaken for an ovarian tumor. Women themselves often intentionally mislead the physician, especially if the pregnancy is illegitimate. They will even carry the deception so far as to go upon the operating table with the full knowledge that they have deceived the surgeon as to their condition.
The physician should always remember the possibility of pregnancy in examining any form of abdominal tumor in women. The mistakes that have happened have usually been the result of carelessness or ignorance on the part of the physician, though some of the most experienced operators have made this error.
The separation of the uterus by bimanual examination as distinct from the abdominal tumor is the most valuable point in the differential diagnosis.
The complication of pregnancy with an ovarian cyst renders the diagnosis more difficult.
It is easier to make a differential diagnosis between an ovarian cyst and pregnancy than between some forms of uterine fibroid and pregnancy.
Repeated examinations are often necessary. It is always advisable, in any case, to make two or more examinations before subjecting the woman to operation. Much which was not at first apparent may be learned by several days of watching and repeated examination.
Phantom tumoris a rare condition. A woman imaginesthat she is suffering from a tumor and that her abdomen is increasing in size. The condition is likely to occur at the menopause, and there may readily be some physical grounds for the woman’s suspicions, because there may be a constantly increasing accumulation of fat in the abdominal walls and the omentum.
The diagnosis is usually easily made. Careful palpation and percussion fail to reveal any pathological mass in the abdomen or any abnormal area of dulness. In these cases the abdomen is often rendered prominent by intestinal tympany. If any difficulty is experienced at the examination, the woman should be etherized. If a satisfactory diagnosis cannot be made, the case should be watched. Several cases have been reported, and there are probably many unreported, in which no tumor was found after the abdomen had been opened.
A fat abdominal wall or omentum has often been mistaken by the woman, and not infrequently by the physician, for a tumor. These cases are often obscure; indeed, all the difficulties of examination, in case a tumor be present, are very much increased by the enormous deposits of fat that are often present in the abdomens of women.
Careful examination, sometimes with anesthesia, and, if necessary, prolonged watching should be practised. If a fold of the abdominal wall be picked up between the hands, it will often show how much of the abdominal enlargement is due to fat.
Tapping.—At one time the universal method of treating cystic tumors of the ovary was by tapping, or puncture through the abdominal wall. Many women were subjected to this proceeding a very great number of times, and, though not cured, were enabled to drag on a miserable existence until death resulted from exhaustion or from some accident to the cyst. In a few cases the cyst refilled very slowly, relief being experienced for severalyears before a second tapping became necessary. In still fewer cases the tapping seemed to be curative, the tumor never reappearing after it had been evacuated. Such cases were so unusual that they should have no influence whatever in determining the method of treatment. In the great majority of instances the cyst rapidly refilled. Sometimes the fluid accumulated with such rapidity that evacuation became necessary every few days. Referring again to the old records, we find a case which was tapped 664 times in thirteen years—once in about seven days!
If the cyst were multilocular, tapping furnished but partial relief.
The proceeding itself was attended by serious dangers. Dr. Fock of Berlin in 1856 stated that 25 out of 132 women—or 1 in 5½—died within some hours or a few days after the first tapping. Another operator lost 9 out of 64 cases—or very nearly 1 in 7—within twenty-four hours after the first tapping. The chief mortality occurred in the cases of multilocular tumors. Tapping the unilocular tumors was attended by much less danger.
The sources of danger from tapping were the following: hemorrhage from puncture of a vessel in the cyst-wall; septic or other infection of the peritoneum; and inflammation or suppuration of the cyst.
The majority of the women died in consequence of peritoneal infection.
The danger arose not only from septic infection of the peritoneum, but from papillomatous or other infection from the escape into the peritoneal cavity of some of the cyst-contents. Reference has already been made to the occurrence of the papillomatous infection at the site of puncture in the abdominal wall.
At the present day tapping an ovarian cyst with the hope of cure is never practised.
Tapping as a palliative procedure should never be performed. The dangers that may result from the tapping cannot be disregarded, and no hope whatever of cure canbe held out to the patient. When operation is finally performed, it is rendered much more difficult from the adhesions that have resulted from previous tappings.
Operation.—The treatment of ovarian cysts is operative. Celiotomy should be performed and the tumor removed without delay. The dangers due to the accidents that may occur show the risk of waiting after a diagnosis has been made. When the tumor is small the operative complications and dangers are at a minimum.
Even if the tumor be discovered accidentally by the physician, and has never given any trouble to the woman, operation for its removal should be advised. A dermoid that has existed for years may suddenly endanger the woman’s life. Delay in the case of papillomatous tumors—and no one can determine in the early stages whether or not a cyst be papillomatous—is especially dangerous. About one-half the women upon whom I have operated for papillomatous cysts have come to me after the peritoneum had become infected. Though the peritoneum be extensively involved, operation is by no means hopeless. As in the case of tuberculosis of the peritoneum, so in papilloma, the opening and draining of the abdominal cavity may result in cure.
Pregnancy is no contraindication to operation. In fact, the dangers of obstructed labor, of rupture of the cyst, and of torsion of the pedicle urgently call for immediate operation in such cases. Pregnancy usually progresses to full term after operation.
Solid tumors of the ovary are of rare occurrence. They are said to be found in about 5 per cent. of all the cases of ovarian tumors that are submitted to operation.
The solid tumors of the ovary are fibromata, myomata, sarcomata, carcinomata, and papillomata.
Fibromata.—Ovarian fibromata are very rare; they are histologically similar to fibroid tumors of other parts of the body. They do not form circumscribed new growths, but affect the whole organ, which becomes uniformly hypertrophied, preserving its general shape and anatomical relations. The tumor may contain, between the bundles of fibrous tissue, small cavities filled with fluid. The growth is usually intra-peritoneal and has a well-formed pedicle; it may, however, in exceptional cases be extra-peritoneal and develop between the layers of the broad ligament. In such a case there is difficulty in determining whether the fibroid originated in the uterus or in the ovary. Ovarian fibromata are usually of small size and slow growth. A case has been reported in which the tumor weighed over 7 pounds.
Corpora Fibrosa.—A variety of the ovarian fibromata are the corpora fibrosa, which are due to fibroid degeneration of the corpus luteum. They are tough, fibrous bodies, about the size of a pea, which are occasionally found upon the surface of the ovary. It is said that they may attain the size of a child’s head. They are usually, however, very small, and have no clinical significance.
Myomata.—Ovarian myomata are composed chiefly of unstriped muscular fiber. They are somewhat more frequent than the pure fibromata. The two growths maybe mixed, forming a fibro-myomatous tumor. The myomatous tumor may attain the weight of fifteen pounds.
Sarcomata.—The majority of solid tumors of the ovary are sarcomatous in character, and it seems probable that many tumors that are classed as fibroids or fibro-myomata are in reality ovarian sarcomata. The growth may be either of the spindle-cell or the round-cell variety. Occasionally it is an endothelioma, a form of sarcoma developing from the endothelial cells of the blood- and lymph-vessels.
Sarcoma of the ovary differs from sarcoma in other parts of the body in the fact that it is very often bilateral. Sutton states that both ovaries are affected in about 20 per cent. of the cases. Other observers state that ovarian sarcomata are usually bilateral.
The surface of the tumor is smooth, and the general form and anatomical relations of the ovary are unaltered. Ovarian sarcomata are usually of median size, though they may attain enormous proportions and fill the abdominal cavity.
The tumor is usually of rapid growth; in one case it attained a weight of ten pounds within a period of six months. The growth is accelerated by pregnancy. Ascites is commonly present with ovarian sarcoma, and cachexia may appear rapidly.
Ascites caused by peritoneal irritation may accompany any of the solid tumors of the ovary, as other kinds of freely movable abdominal tumor. It is, however, especially characteristic of the ovarian sarcomata, and is a point of diagnostic importance.
Ovarian sarcomata differ from the fibroid and the myomatous tumors in rapidity of growth, involvement of both ovaries, and the presence of ascites. Ovarian sarcomata may occur at any age. They are relatively very frequent in children. An analysis of 60 cases of ovarian tumors in children collected by Sutton shows that sarcomata occurred 16 times.
The symptoms caused by ovarian fibromata, myomata,and sarcoma are those referable to pressure and peritoneal irritation. These tumors, on account of their moderate size and great mobility, seem to be especially liable to torsion of the pedicle. They should be removed by celiotomy as soon as recognized.
Both ovaries should always be carefully examined, for in sarcoma the disease is often bilateral.
Carcinomata.—Primary cancer of the ovaries is very rare. Secondary infection of these organs is, however, of not infrequent occurrence. It is found in cases of cancer of the breast and of the uterus. In 29 cases of death from cancer of the breast, both ovaries were found to be involved in 3 cases.
Primary cancer of the ovary appears as a solid or a cystic tumor. The solid carcinomata are diffuse infiltrations of the ovarian tissue, forming pedunculated, rarely intraligamentous, ovoid or globular tumors having a smooth or slightly irregular surface. They are either of the medullary or scirrhous type. The medullary form is of rapid growth, and may reach the size of the adult head. The scirrhous form is of comparatively slow growth and smaller size, and in consistency resembles a fibroma.
The cystic carcinomata are similar in form to the multilocular glandular cysts, but are smaller, rarely reaching a greater size than that of the adult head. They are adeno-carcinomata or papillary adeno-carcinomata. The surface of the tumor, its walls, and the septa contain to a greater or less extent solid nodules or plates of various size composed of carcinomatous tissue. The nodules often have a papillary character.
Ovarian carcinoma is usually a bilateral growth. Unlike carcinoma in other parts of the body, it may, particularly the medullary form, occur in childhood. It is usually found between the ages of thirty and sixty years. Ascites is commonly present in cancer of the ovaries, the fluid being often tinged with blood; as the disease develops, edema of the lower limbs and cachexia appear.
Cancer of the ovary is an extremely malignant growth,quickly extending to surrounding structures as implantations on the peritoneum, and by metastasis to distant organs. In more than 75 per cent. of the cases operated upon the disease has returned and terminated in death within the first year.
When cancer of the ovaries is secondary to cancer elsewhere than in the uterus, operation offers no prospect of cure. If the disease is secondary to cancer of the uterus, it may be possible to remove all of the affected structures.
Ovarian Papillomata.—Superficial papillomata of the ovary are of very rare occurrence. In many of the cases in which the papillomata appear to grow from the surface of the ovary there had previously been a papillomatous cyst of paroöphoritic origin, which had become perforated and perhaps inverted, so that, after the cyst had become destroyed, the growths appeared to spring from the ovarian surface. Careful dissection and search for the remains of the old cyst should always be made in such cases.
In superficial papilloma of the ovary the growths are in all respects similar to those found in the interior of papillomatous cysts. They may be isolated upon the surface of the ovary, or they may cover it so completely that the ovary is hidden from view. A section, however, will reveal the ovary lying in the centre of the growth.
The papillomata may be pedunculated or sessile. They vary in size. In some cases they form a mass larger than the adult fist.
The disease is often bilateral. Secondary involvement of the peritoneum occurs, as in the case of papillomatous cyst. The course of the disease is similar to that of a perforated papillomatous cyst. The treatment is immediate celiotomy and removal. As in the case of papillomatous cysts, involvement of the peritoneum is no contraindication to operation.
Tuberculosis of the Ovary.—Tuberculosis of the ovary is usually secondary to tuberculosis of the Fallopian tubes. In tuberculosis of the peritoneum the ovariesare often found to be involved, in some cases without accompanying disease of the tube. In phthisical women the ovaries have been found, in rare instances, to be the only portion of the genital apparatus in which secondary deposit of tubercles took place.
Williams states that primary tuberculosis of the ovaries has not yet been described.
The surface of the ovary may be covered with miliary tubercles, or they may be scattered through the substance of the gland. In other cases the ovary contains cavities filled with cheesy material or pus, forming a tuberculous abscess.
There are no characteristic symptoms of tuberculosis of the ovaries. The condition is usually found at operation or at autopsy, associated with tuberculosis of the peritoneum or of some other part of the genital organs, as the Fallopian tubes and the uterus.
The treatment consists in oöphorectomy, unless operation is contraindicated on account of extensive involvement of other structures.
Tumors of the Ovarian ligament.—Fibroid and sarcomatous tumors have occasionally been found in the ovarian ligament. Doran has reported a fibroid of the ovarian ligament that weighed 17 pounds. The writer has removed a sarcoma of the ovarian ligament that weighed 5 pounds.
It is impossible to distinguish these tumors from similar growths of the ovary. They demand like treatment.
Congenital malformations are found in all parts of the genital tract. Some of the more common forms, like arrested development of the uterus, have been referred to in the previous pages. Others will briefly be considered here. Reference to the method of development of the sexual organs will elucidate this subject.
The Fallopian tubes, the uterus, and the vagina are developed from two embryonic structures called the ducts of Müller. These ducts become fused, first at the lower extremity, between the sixth and eighth weeks of fetal life (Fig. 175). The early genital tract thus formed is consequently divided throughout by a septum, which normally disappears during fetal development, so that there results one vaginal and uterine tract, from which the Fallopian tubes branch.