CHAPTER XVII THE DIAGNOSIS OF DISEASES OF THE OVARIES (Part 1)

CHAPTER XVII THE DIAGNOSIS OF DISEASES OF THE OVARIES Anatomy and age changes, p. 284. Anomalies, p. 285. Atrophy, p. 285. Displacements, p. 286: Undescended ovary, p. 286. Prolapse of the ovary, p. 286. Hernia of the ovary, p. 288. Inflammations (Ovaritis), p. 288: Acute ovaritis, p. 288; Diagnosis of acute overitis, p. 288. Chronic ovaritis, p. 290. Diagnosis of chronic ovaritis, p. 290. Tumors of the ovary, p. 291 : Modes of development, p. 292. Classifica- tion, p. 293. Malignancy, p. 293. Etiology and symptoms, p. 293. Di- agnosis in general, p. 295. Diagnosis of small ovarian tumors, p. 296; Differential diagnosis of small ovarian tumors, p. 296. Diagnosis of large ovarian tumors, p. 301; Differential diagnosis of large ovarian tumors, p. 305. Tables, pp. 308, 309. Complications of ovarian tumors, p. 315: 1. Adhesions and incarceration, p. 315. 2. Intraligamentous development, p. 316. 3. Torsion of the pedicle, p. 317. 4. Infection and suppuration, p. 318. 5. Degenerative processes, including malignancy, p. 318. 6. Rupture, p. 319. 7. Association with pregnancy, p. 320. Diagnosis of the different pathological varieties of ovarian tumors, p. 321. ANATOMY AND AGE CHANGES At birth the ovary is an elongated body, lying parallel with the Fallopian tube and resembling in shape a flattened cucumber. (See Fig. 117.) Its surface is smooth, its borders may be crenate, and it may have a longitudinal furrow. At puberty it has become transformed into a smooth olive-shaped gland, grayish-pink in color, If inches long (4 cm.), J to 1 inch broad (2 to 2.5 cm.), and J inch thick (1 to 1.5 cm.) and weighing about 2 drams (6 grams). From puberty to the menopause it maintains the same size and shape, but the smoothness of its surface is marred by scars, the results of repeated lacerations caused by the rupture of the ripe Graafian follicles. (See Fig. 118.) After the menopause the ovary shrinks and becomes wrinkled and atrophic, and at the age of seventy weighs about one gram. (See Fig. 119.) 284 ANOMALIES ANOMALIES Congenital absence of both ovaries is rare and is associated with defective development of the uterus and partial or complete ab- sence of the vagina. Absence of one ovary usually accompanies deficiency of the corresponding half of the uterus and the Fallopian tube, and absence or misplacement of the kidney on the same side of the body. There is on record no reliable description of a super- numerary ovary: the bodies described as such being corpora fibrosa, small myomata of the ovarian ligament, or partially detached tubes uterus Fimbria ucarica. Fig. 116.— The Ovary and Tube Seen from Behind. Henle.) of the parovarium. Faulty growth of the ovary is commonly associated with the uterine condition known as infantile uterus, also with rudimentary uterus. Atrophy of the ovaries occurs normally at the menopause. They become smaller and harder and the oophoron (the egg-bearing zone on the outside of the ovary) is transformed into a layer of dense fibrous tissue. Lactation (itr<>/>lii/ is a shrinkage in tin of the ovary occurring Bometimes in women who have nursed their children for a long time. Ovarian atrophy has been reported m the exanthemata, myxedema, marked anemia, and in diab It is supposed to occur in connection with rapidly acquired «''»« 286 DIAGNOSIS OF DISEASES OF THE OVARIES At all events young women who have suddenly become fat fre- quently suffer with amenorrhea. On account of the increase in fat in the abdominal walls it is not easy to determine a decrease in the size of the ovaries in these patients, but in certain cases atrophy has been definitely made out. In 1900 I opened the abdomen in a case of absolute amenorrhea of eight months' duration following steaming of the uterine cavity at the hands of another practitioner. The woman was twenty- eight years old, the mother of two children. The ovaries were found to be partially atrophied as well as the uterus. DISPLACEMENTS OF THE OVARY (a) Undescended ovary, (b) Prolapse of the ovary, (c) Hernia of the ovary. (a) Undescended Ovary. — The ovaries are in close relation with the kidneys in the embryo and they gradually move downward -—^ Tube >■-:". . .,'-■ " ■ --. ' ^ft; 21 ^QuT f-r't ng<;s Ov ary^ _ Cervix w Fig. 117.— Uterus, Tubes, and Ovaries of an Infant One Month Old. to the pelvis, at birth lying on the psoas magnus muscle in close relation with the internal abdominal ring. They get to their normal situation in the adult soon after birth. It may happen in very rare instances that an ovary may remain in the neighborhood of the kidney and may retain its infantile shape. If it is the right ovary that has failed to descend the cecum also generally remains high up, in its fetal position. (b) Prolapse of the ovary may occur when from repeated preg- DISPLACEMENTS OF THE OVARY 287 nancies the ovarian and broad ligaments have been stretched and subsequently not properly involuted, permitting the ovary to sag back into Douglas' cul-de-sac. Also when an ovary is enlarged for any reason and thus gravitates of its own weight to the pelvic floor. Misplacements of the uterus, such as retroversion and retroflexion, are commonly associated with prolapse of the ovaries. Prolapsed ovaries may be tender to touch, when we may assume that they are the seat of inflammation, ovaritis. In this event Utero - o v arian I i g anient Tube Broa d tig- es.me-\t Fig. 118.— Ovary and Tube of a Woman during Sexual Maturity they may cause suffering when pressed on during the ac1 ol del tion, especially the left ovary, or during coitus. The diagno established by the bimanual tough. Absence of the ovary in its normal situation and its presence a1 the base of the broad ligament as determined by rectal touch are tin- diagnostic points. It is often difficult to differentiate a prolapsed ovary from a small scybalous mass in the rectum. In order to do this successfully, 288 DIAGNOSIS OF DISEASES OF THE OVARIES thoroughly cleanse the rectum by enema, and examine a second time. In some cases it is well to use the proctoscope to be sure that the upper rectum is free. If the ovary is tender distinguish- ing it is easier. (c) Hernia of the ovary is comparatively rare in adults but occurs not infrequently in infants under a year and a half old. It may occupy a hernial sac either alone or accompanied by its Fallopian tube. Ovarian hernia is more apt to occur as an inguinal than as a femoral hernia. Congenital hernia of the ovary is very rare, but it may occur in the early months of infancy because the ovaries and tubes at this time normally lie in close prox- imity to the abdominal ends of the inguinal canals. (See Fig. 206.) Many cases reported as hernia of the ovary are hydroceles of the canal of Nuck. Hernia of the ovary may occur at any age up to the seventy-third year. The diagnosis can be made definitely only by operation. It is difficult to be sure of the absence of the ovary on one side. A hernia — preferably an inguinal hernia — having a tender body in it, while at the same time the ovary on that side can not be palpated in its normal situation, makes a probable diagnosis. INFLAMMATIONS OF THE OVARY Ovaritis may be acute or chronic. The acute form occurs in infections following labor or abortion, gonorrhea, typhoid fever, miliary tuberculosis, the acute exanthemata, or mumps. The ovary is enlarged and congested, the oophoron or the paroophoron being involved, or both. The tissues are infiltrated with serum, leucocytes which have escaped from the blood-vessels, and some- times with blood. If there is a large collection of blood, a hema- toma of the ovary is formed. Abscess of the ovary may be the result of severe grades of inflammation and a tumor which reaches the size of an egg may eventuate. There are apt to be adhesions to the surrounding structures, such as the Fallopian tubes and in- testines. The abscess may rupture into the intestine, bladder, or vagina. It has been known in rare cases to break into the general peritoneal cavity, causing fatal peritonitis. Diagnosis of Acute Ovaritis.— Pelvic pain aggravated by move- INFLAMMATIONS OF THE OVARY merit of the body or by defecation, and tenderness on pressure in the ovarian regions, are characteristic of a mild attack of ovaritis. Chills and marked elevation of the body temperature are to be expected if suppuration occurs. If there is peritonitis of any extent there will be rigidity of the abdomen and a rapid and small pulse and increased pain. If it is possible to palpate the ovary it will be found enlarged and exquisitely tender. Commonly the rigidity of the abdominal walls prevents exact differentiation of the structures involved. An abscess is usually fixed in a ma— of exudate. Fluctuation may be made out by rectal palpation, but - Utc rus Tu.be J J^ J'^SA Atrophied / ^^^S^B^^ ovary \ , JttM g?''"^ I _JrW'^F 40 '•■ \ .-~jT jta ^>y »"»< 1 ied-^ervt ~a^Bt?*' BP^ Fig. 119.— Senile Ovary and Tube. often the wall of the abscess is so thick thai this is impossible. In the case of acute ovaritis il is impossible to distinguish exactly between ovaritis and salpingitis. If the disease is right-sided we must, if possible, eliminate appendicitis. The history of the onsel is the important point in distinguishing the two. Acute pelvic inflammation is generally preceded by a vaginal discharge or other uterine symptoms such as dysmenorrhea, whereas in appendicitu there is a history of digestive disturbances, such as diarrhea alter- nating with constipation, or of previous attacks of pain m ' right lower abdomen. The pain of pelvic disease is dull and - and is situated deep in the pelvis, pressure over Poupart'a ligament 19 290 DIAGNOSIS OF DISEASES OF THE OVARIES occasioning great suffering. The pain of appendicitis is sharp and colicky and is higher in the abdomen and is more diffused. If the appendix happens to be in the pelvis or if there is much peritonitis it is impossible to distinguish the two affections. Chronic ovaritis may follow an acute ovaritis or it may originate in an infection of the uterus, especially in gonorrhea. It is also found in the presence of fibromyomata and large ovarian tumors of the opposite side, although the disease is generally bilateral. The oophoron is usually affected, the Graafian follicles often be- coming enlarged and causing atrophy of the stroma because of their size. Such a condition is called small cystic degeneration. In certain cases the entire cortical region of the ovary (oophoron) is trans- formed into little cysts containing a clear fluid, the ovum having dis- Fig. 120. — Diagram Showing the Cyst and Tumor Regions of the Ovary. (After Bland-Sutton.) appeared. Now and then a few normal follicles may be found. In some cases of chronic ovaritis, the stroma and not the follicles is in- volved. In the late stages of this disease the ovary is found small and scirrhotic with a puckered, uneven surface, as from many scars. Diagnosis of Chronic Ovaritis. — There is nothing pathognomonic in the symptoms of this disease. There is apt to be pain in the ovarian regions, and scanty menstruation if the ovarian stroma has been destroyed, also dysmenorrhea. The ovaries may be tender to the touch; often they are not. The bimanual touch may determine follicular enlargement or a nodular feel. In only ex- ceptional cases when all the factors are favorable, more especially at an examination under an anesthetic, can a small cirrhotic ovary be diagnosed. OVARIAN TUMORS 291 OVARIAN TUMORS We have considered already certain states of the ovary that strictly may be classed as tumors, for instance, "small cystic de- generation" and inflammatory conditions with enlargement. Let us now take up ovarian tumors proper, counting as tumors all enlargements of the ovary greater in size than a hen's egg, using Pfannenstiel's classification based on the origin of the tumor. (Veit's "Hanclbuch," J. Pfannenstiel, "Die Erkrankungen des Ovarium.") A. Nox-Proliferatixg Cysts. (Follicular cysts; Cysts of the corpus luteum.) B. New Formations. I. Parenchymatogenoiis Tumors. (Tumors arising from germinal or follicular epithelium or from the ovum.) 1. Epithelial New Formations. (a) Cystoma serosum simplex. (Simple cyst.) r Pseudomucinosum. I (Multilocular cysts. (b) Cystadenoma ; a w J Serosum. [ (Papillary c\ (c) Carcinoma. 2. Embryomata. (Tumors springing from the ovum.) (a) Dermoid cysts. (b) Teratomata. II. Stromatofjcjious Tumors. (Tumors arising from the connective tissue.) 1. Fibroma. 2. Sarcoma. 3. Peri- and Endothelioma. C. Mixed Tumors. (Various combinations of the tumor processes enumerato d. Fig. 120 shows diagrammatically the differenl portion ovary affected by neoplasms. 292 DIAGNOSIS OF DISEASES OF THE OVARIES Modes of Development of Ovarian Tumors The accompanying diagrams indicate the method of develop- ment of the pedicle of a tumor and the arrangement of the peri- toneum in the case of the normal ovary, a free ovarian cyst, an intraligamentous cyst, and an adherent ovarian cyst. It is plain that the broad ligament, the Fallopian tube, the round ligament, TMicle. fallopian '■ tube V?f\7v.lhpiaqtube vyesosalpiqy- Q))tfouncl 7/gameqt- Figs. 121-124. — Four Diagrams Showing the Method of Formation of the Pedicle in the Different Sorts of Ovarian Tumors. and the ovarian ligament are included in varying degrees in the pedicle of a large non-adherent ovarian tumor. Commonly the Fallopian tube is much elongated and spread over the surface of the tumor, the round ligament comes on to the anterior face of the tumor, and the ovarian ligament is much enlarged and lengthened. In the case of tumors developing between the layers of the broad ligament, or of adherent ovarian tumors, the conditions are as shown in the diagram. A parovarian cyst may lie free in the OVARIAN TUMORS pelvis attached only by a pedicle formed from the broad ligament, and it is not unusual to find such a cyst as a complication of a small ovarian tumor. Classification Ovarian tumors have been generally classified as solid or cystic, and benign or malignant. As will be seen from the classification of Pfannenstiel, such a division is arbitrary and many of the tumors are both solid and cystic, and also benign and malignant. This is shown by careful microscopic examination in the pathological laboratory where a unilocular cyst will be found often to have small cysts in its walls, or trabecular in the cyst walls, denoting former subdivisions. Some of the multilocular cysts show papillary masses in certain regions, while in other places small dermoid cysts may be discovered, and even areas of cancerous degeneration. Malignancy A benign tumor is one which does not tend to recur when extir- pated, as well as one which does not implant itself elsewhere or invade the tissues. A malignant tumor signifies a growth which tends to destroy life by invasion of the surrounding tissues as well as one which dis- tributes its elements by metastasis to other part- of the body. In a general way one may say that the cystadenomata (multi- locular cysts), the parovarian cysts, the fibroids of the ovary, and the dermoid cysts are benign; the carcinomata and sarcomata are malignant, and the papillary tumors are od the border land. That is to say, the papillary cystadenomata tend to implant their ele- ments on the surrounding structures, there to grow, but they do not invade the underlying structures as do the carcinomata and sarcomata. Etiolocy WD Symptoms Ovarian tumors are found most often during the time of Bexual activity in the life of women, but may occur at any age. Chiene 294 DIAGNOSIS OF DISEASES OF THE OVARIES and F. B. Lund have each removed an ovarian cyst from a child three months old, and Thornton operated successfully on a woman ninety-four years of age. It is supposed that the germ of most tumors exists from fetal life and that when the proper stimulant comes the tumor develops. Fig. 125. — Very Large Ovarian Cyst with Characteristic Emaciation about the Chest and "Facies Ovarina." (Kelly.) The controlling factors are unknown. The symptoms consist, during the early stages of the growth of an ovarian tumor, in the usual syndromata of uterine disease, and may be of little moment to the patient, so that her attention is not directed to the pelvis. They are menstrual disturbances, — such as dysmenorrhea, menor- OVARIAN TUMORS 295 rhagia, or scanty menstruation,— a sense of weight in the pelvis, or, if there is peritonitis, pain. When the tumor attains a considerable size, so that it fills the pelvis or rises out of it into the abdomen, there are pressure symptoms. These are vesical or rectal tenes- mus, frequent micturition, and constipation; in the case of large tumors, edema of the vulva and of the lower extremities caused by pressure on the iliac veins; also hemorrhoids. In rare i there have been noted albuminuria and suppression of urine from hydronephrosis caused by pressure on the ureters. Other symp- toms are jaundice from occlusion of the bile ducts, ascites from pressure obstruction to the portal system, dilated veins in the skin of the abdomen, the occurrence of the white lines in the .-kin known as linese albicantes, occasional umbilical hernia, and de- rangements of digestion and dyspnea. Pain in the abdomen is a symptom of adhesions, as a rule, and great- care should be observed in taking the anamnesis to get the exact sit- uation, character, and duration of the pain. Pain is caused also by traction or torsion of the pedicle and by secondary changes in the contents of the cyst involving adhesions to the sensitive parietal peritoneum. The fades ovaiina is a peculiar facial expression that i- pathog- nomonic of the late stage of large ovarian tumors. It consists of an anxious, careworn look; the face is pale and shriveled, there being wrinkles in