CHAPTER XVII THE DIAGNOSIS OF DISEASES OF THE OVARIES (Part 2)

the cheeks, and it looks longer; the nostrils are wide and the lips thin, the space between the eyelids and the bony margin of the orbits is sunken. The face does not have thai yellowish hue characteristic of the late stages of cancel-, nor yel the full appearance of the face of the pregnant woman. There is also to be noted in large ovarian tumors a loss of flesh over the chest and shoulders, probably of a piece with the atrophy of the face just described. Diagnosis in Geneb \l In considering the diagnosis of ovarian tumors it is convenienl to divide them into small tumors, those that lie wholly within the pelvic cavity proper, and large tumors, those that li<- i"i the part in the abdominal cavity. We will discuss the d and 296 DIAGNOSIS OF DISEASES OF THE OVARIES the differential diagnosis of each, then take up the complications of ovarian tumors, and finally say something of the diagnosis of the different pathological varieties of tumors, as far as they can be distinguished without operation. The important factor in the diagnosis of all ovarian tumors is to determine the relation of the tumor to the uterus. If it can be shown that moving the tumor moves the uterus, or, conversely, that changing the position of the uterus moves the tumor, there is a probability that the tumor is ovarian. On ac- count of adhesions and intraligamentous development, all ovarian tumors are not movable. The tumors of medium size, those that have risen out of the pelvis but have not yet distended the ab- dominal walls to excessive degree, are easiest to palpate with reference to their connection with the uterus. To perform the palpation to the best advantage, use is made of the bimanual vagino-abdominal touch. With the forefinger against the cervix, push the tumor in the abdo- men or pelvis to one side with a quick movement of the hand on the abdomen. At the same moment the cervix will be felt to move be- cause of the pull on the pedicle of the tumor. Sometimes, but not often, a quick push on the uterus by the finger in the vagina will be transmitted to the tumor, as detected by the hand on the abdomen. To palpate the pedicle the cervix is grasped by a double tenacu- lum held by an assistant while the physician practices the bimanual recto- abdominal touch, with two fingers in the rectum. (See Fig. 126, page 301.) In this way it is possible sometimes to get a good idea of the situation, size, and length of the pedicle of a tumor. As pointed out by John A. Sampson (" Surgery, Gynecology and Obstetrics," 1907, Vol. IV., p. 685), traction on the pedicle of an ovarian tumor causes pain. Also twisting of the pedicle, as determined by opera- tions performed on patients by the aid of local anesthesia, causes pain which is referred to the pelvis on the side on which the pedicle is situated. Diagnosis of Small Ovarian Tumors Those tumors, which lie entirely within the cavity of the true pelvis, are diagnosed by the bimanual touch, both vagino-abdominal SMALL OVARIAN TUMORS and recto-abdominal. In the case of the small tumor it is difficult to make out the characteristics of the pedicle. One determines this in some cases as described above. We try to ascertain the position, size, form, and density of any given pelvic tumor; then its relation to the uterus. If the tumor is small there is a likelih< >< x 1 that the uterus can be placed and its size and shape defined by touch. In the larger tumors, those filling the pelvis, such palpa- tion is difficult or impossible. In this event the sound must be passed to determine the location and relative size of the uterus. As a rule, ovarian tumors are round. This is always the case with the cysts, the solid tumors being generally, but not invariably, round. A fluctuating consistency can be made out in most a of cysts. A small-sized ovarian cyst is to be looked for in the situation of the ovary, and is movable (rarely adherent) ; an int ra- ligamentous cyst lies to one side and behind the uterus, and is immovable. A cyst may lie in front of the uterus, rarely, and, of course, there may be two ovarian tumors, one on each side. Differential Diagnosis of Small Ovarian Tumors We must rule out. : 1. Ovaritis. 2. Subperitoneal fibroid. 3. Parovarian cyst. 4. Hydrosalpinx, hematosalpinx, and pyosalpinx. 5. Encapsulated peritonitis, or inflammatory exudate. 6. Echinococcus cyst. 7. Extra-uterine pregnancy. 8. Early normal pregnancy, or cornual pregnancy. 9. Distended urinary bladder. i. Ovaritis. — Tumors of the chronic form of ovaritis are seldom larger than a pigeon's egg, but the acute form resulting in abe may be of considerable size Here there is fever, and the tumor is of recent occurrence, an acute affair. The tumor is ten. Id-, and there is pelvic peritonitis in varying degress of intensity as evi- denced by rigidity of the abdominal walls. Also there is generally a history of infection. 2. Subperitoneal Fibroid.— The differentiation in this ften 298 DIAGNOSIS OF DISEASES OF THE OVARIES a difficult matter and depends entirely on the findings from palpa- tion. The consistency of an ovarian cyst is softer than that of a subserous fibroid. As a rule, the fibroid is more intimately allied with the uterus, and in many cases the pedicle is short and thick or the growth is sessile. It helps in the diagnosis if other fibroid nodules can be distinguished in the substance of the uterus, for fibroids are apt to be multiple. The coexistence of ovarian cyst and fibroid is not an uncommon occurrence. In the case of an interstitial fibroid the uterus should be enlarged and menorrhagia is apt to be a symptom; the passage of the sound will show an increased depth of the uterine cavity. If, by any chance, both normal-sized ovaries can be palpated, the tumor is a uterine fibroid. 3. Parovarian Cyst. — Parovarian cysts are generally relatively small in size, therefore they are put here. They may be large, however. The cyst arises from the epoophoron, is generally uni- locular, and has a thin wall, with clear serous contents. It is situ- ated between the tube and ovary and is intra-ligamentous in growth; therefore, when the cyst has developed the tube is on its upper surface and the ovary below it. In extremely rare cases the ovary may be palpated by the finger in the vagina on the under surface of the cyst. As a rule, the differential diagnosis can not be made. 4. Hydrosalpinx, Hematosalpinx, and Pyosalpinx. — The accumu- lation of serous fluid, blood, or pus in the Fallopian tube gives it a more or less characteristic shape. This is a strong diagnostic point. A pyriform swelling with its small end at the uterine horn is indicative of a dilated tube. In the case of hydrosalpinx and hematosalpinx there is, as a rule, no complicating peritonitis, therefore the diagnosis is easier than in the case of pyosalpinx, which is apt to be surrounded by exudate. Hydrosalpinx and hematosalpinx never reach the great size of exceptional cases of pyosalpinx. It is unusual for any variety to be more than an inch and a half (3 cm.) in diameter or five inches (12 cm.) long. The hydrosalpinx has a thin wall, and fluctuation can be determined without much difficulty; pyosalpinx has thick walls because of inflammatory action in the tube and also in the peritoneum sur- rounding it, and it is not easy to make out fluctuation. 5. Encapsulated Peritonitis. — If a quantity of serous or purulent SMALL OVARIAN TUMORS exudate in the case of pelvic peritonitis, or a quantity of ascitic fluid becomes encapsulated by peritoneal adhesions, the condition may be mistaken for a cystic tumor of the ovary. Such a condi- tion is relatively rare, however. Generally there is evidence of tuberculosis or carcinosis or actinomycosis of the peritoneum and the manifestations of the disease in the general cavity of the peri- toneum overshadow those in the pelvic cavity. Such ciicu in- scribed collections of fluid in the pelvic cavity have an irregular shape and are not often round. Also fluid is apt to be present in other portions of the peritoneum. 6. Echinococcus Cyst. — Echinococcus cyst of the pelvis is rare. Primary echinococcus disease of the ovary is unknown, but it occurs in the following situations in the pelvis: (a) the uterus, (b) the mesometrium, (c) the pelvic bones, (d) the omentum, an.! (e) the Fallopian tubes. Also downward extension of hydatid disease of the liver may reach the pelvis. Echinococcus cysl is round and fluctuates; but, as a rule, is more distended and has thicker walls than an ovarian tumor, and it is generally densely adherent to the surrounding structures. Bland-Sutton ("Surgical Diseases of the Ovaries and Fallopian Tubes."' L891, p. 183 says that a " peculiar sign — hyatid fremitus — can sometimes be obtained by placing the palm of the left hand upon the tumor and sharply percussing with the finger of the right. It is a peculiar tremor or thrill, only felt over a hyatid cyst."' In thiscountry hydatid dis- ease is very rare. 7. Extra-Uterine Pregnancy. — This gives a history of pregnancy. Before rupture there is a boggy fluctuating or elastic tumor at the side and back of the uterus. It is the shape of a distended tube. Look for purple discoloration of the vagina with increased dis- charge, and for changes in the breasts together with uterine en- largement and softening of the cervix, also pain <>n moving the cervix. About the time of intra-abdominal rupture of the p nant sac the endometrium casts off a modified decidua of pregnane) with more or less uterine hemorrhage. At the time of rupture the symptoms are 1 hose of hit ra-abdominal hemorrhage and an There is a fulness in the cul-de-sac with abdominal distention, rapid, feeble pulse, severe pain in the abdomen, and collapse. It in a chronic case a hematocele has formed, there U a bo in the cul-de-sac, generally filling the pelvis, the uterus beii 300 DIAGNOSIS OF DISEASES OF THE OVARIES front. There may be a history of repeated attacks of pain recurring at irregular periods. 8. Normal Pregnancy. — Early normal pregnancy, particularly if the pregnancy begins in one horn of the uterus, may be mistaken for ovarian cyst. It should not be forgotten that the two condi- tions frequently coexist. First, the history indicates pregnancy. Inquire for amenorrhea and morning nausea and whether there has been coitus. The uterus in pregnancy is anteflexed, there is bulging of the lower uterine segment anteriorly, the uterine tissues have a peculiar elastic feel and are compressible by bimanual touch (Hegar's sign; see Fig. 178). The cervix is soft and there are increased vaginal discharge and purplish discoloration of the anterior vaginal wall and introitus vaginae, noticeable as early as the sixth week in some instances, though usually not quite so early. The breasts are full, the veins showing in the skin; the areolae are pigmented and show enlargement of the follicles. There may be secretion from the breasts. In the case of pregnancy in one horn of a bifurcated uterus the history of pregnancy is to be obtained. There is no bulging of the lower uterine segment, but the other signs of pregnancy are the same. There is no fluctuation in the pregnant uterus until the stage of "ballottement." This is not available as a diagnostic sign until the twenty-first week of preg- nancy when there is sufficient fluid in the amnion and the fetus is heavy enough to give the characteristic feeling as the fetus bobs about when jostled by the sudden impact of the examiner's finger in the vagina. 9. A Distended Urinary Bladder. — If the rules for the preparation of the patient for an examination have been observed (see Chapter IV., page 23) it will have been learned that the patient has been unable to urinate, and therefore a catheter has been passed. It sometimes happens that a patient is unable to speak the language or is unconscious, and the question of ovarian tumor arises. It is safe to pass the catheter if there is the slightest doubt that the bladder is empty. Upon palpation the full bladder is not so mov- able as an ovarian cyst, as a rule, and the uterus is retroverted under the bladder. Dribbling of urine is apt to be a symptom of an overfilled bladder. LARGE OVARIAN TUMORS 301 Diagnosis of Large Ovariax Tumors Large ovarian tumors are those which are too large to be con- tained in the true pelvis and are of abdominal development. They fill the abdomen to a greater or less degree and lie on the false pelvis. The diagnosis depends in great measure on the determina- Fig. 126.— Hegar's Method of Determining the Relation ofTumors to the [Jterra tion of the connection of the tumor by pedicle with one or the other side of the fundus uteri. If the tumor is very large such determination is difficult of accomplishment. If the tumor Is smaller, so that there is space to mow it within the abdominal walls, moving the tumor will be felt by the finger in the vagina <<> pull the uterus at the same time. By rectal palpation, after trac- tion on the cervix has been made by a double tenaculum, the pi 302 DIAGNOSIS OF DISEASES OF THE OVARIES cian may be able to distinguish the situation and characteristics of the pedicle. (See Fig. 126, page 301.) Inspection. — Inspection of the abdomen of a woman having a moderately large ovarian tumor will show the enlargement most pronounced on the side from which the tumor has sprung. This is not the case with very large tumors. As a rule the enlargement is in the lower portion of the abdomen. B. C. Hirst (" Diseases of Women," Second Edition, p. 539) has seen three cases in which an ovarian tumor was in the upper abdomen — twice due to tight lacing and once to the fact that the tumor was elevated in preg- Dull Tympanitic Tympanitic Fig. 127. — Diagram of a Cross Section of the Body in the Case of an Ovarian Tumor. nancy, became adherent to the liver, and did not descend with involution of the uterus. When the tumor has been long existent we expect to find the fades ovarina and loss of flesh about the chest and shoulders. Unless ascites is present or the tumor is excessively large, there is no bulging in the flanks. Palpation. — Palpation usually shows a fluctuating tumor, more distinctly felt on the affected side. The elasticity will depend on the sort of tumor present, and on the tenseness of the cyst. If the tumor is very tense it may feel like a solid mass. It is rare for solid tissues to predominate in ovarian tumors. Nodules may be felt and loculi of a multilocular tumor if the abdominal walls are thin. If the walls are very tense or thick it is necessary often to LARGE OVARIAN TUMORS 303 administer an anesthetic before a satisfactory examination can be made. The mobility of the tumor depends on the length of its pedicle, the relation between the size of the tumor and the size of its abdomen, and the presence of adhesions. By means of the bimanual vagino-abdominal or recto-abdominal touch it may be possible to determine that the uterus is not en- larged and is separate from the tumor, and the pedicle may In- mapped out by traction on the uterus. Also the connection of the tumor may be made plain by moving the tumor suddenly, the ini- Fig. 128. — Large Parovarian Cyst Seen in Profile. (Kelly.) pulse transmitted to the uterus being appreciated by the finger in the vagina or rectum. Percussion. — With the patient in the dorsal position the tumor occupies the lower anterior portion of the abdomen. The intefi tines, held by their mesentery, are Dearer tin- diaphragm and at the sides of the tumor; therefore tympanitic resonance is found in the epigastrium, flatness over the tumor, and dullness or modi del resonance in the flanks. These areas of resonance, flatness, and dullness do not change with change in the position of the patient, as regards the side position or the standing position. If the tumor contains fluid, a percussion wave may be elicited by placing a hand on each side of the abdomen and then tapping with the finger of 304 DIAGNOSIS OF DISEASES OF THE OVARIES one hand. A vibration will be felt by the opposite hand. If the abdominal walls are very fat the fat may transmit a wave by itself; therefore, to eliminate this fat wave have an assistant place a hand with the ulnar edge down along the middle line of the ab- Fig. 129. — The Various Abdominal Organs from Which Tumors May Arise. (Kelly.) domen and press firmly. If the fluid in the cyst is thick, as in dermoids, the percussion wave may be slight or absent. Measurements. — Measurements of the abdomen show an increase or decrease in the size of a tumor from time to time. They are LARGE OVARIAN TUMORS 305 made with a tape measure at some definite point, as about the body at the umbilicus, or at the anterior superior spines of the ilia. Other measurements are, the distance from the tip of the ensi- form cartilage to the upper margin of the symphysis pubis and a measurement made with the pelvimeter, the patient being in a standing position, from the upper apex of MichaehV rhomboid area on the back over the sacrum, to the most prominent point of the tumor. These measurements must be taken each time with the patient in exactly