CHAPTER XVII THE DIAGNOSIS OF DISEASES OF THE OVARIES (Part 3)

the same position, whether standing or on the side and always with the bowels free. Aspiration or tapping an ovarian tumor is never justifiable as a means of diagnosis, and exploratory incision is to be practiced only when it is impossible to make a diagnosis and all the preparations have been made for a complete operation. Differential Diagnosis of Large Ovarian Tumors We must rule out: 1. Pregnancy. ■ 2. Ascites. 3. Fibroids. 4. Accumulations of gas or fecal matter in the intestines. 5. Fat or tumors in the abdominal walls, including "Phantom Tumor." 6. Cyst of the pancreas. 7. Tumors of the spleen, liver, and kidneys. 8. Cyst of the omentum. 9. Echinococcus cysts. 10. Dilated stomach. 11. Distended urinary bladder. i. Pregnancy. — It should be assumed, until the contrary has been proven, that every abdominal enlargement in a woman is due to pregnancy. In this way many embarrassing mistakes will be avoided. The diagnosis of early pregnancy lias been considered in treating of the small ovarian tumors. Advanced pregnancy is to be excluded by the history. It is possible to have amenorrhea in ovarian tumor, especially where both ovaries have become dis- 20 306 DIAGNOSIS OF DISEASES OF THE OVARIES organized by the disease affecting them, but it is unusual. Morn- ing nausea and vomiting during the early months, or salivation and heartburn and swelling of the breasts, are characteristic of preg- nancy. Sometimes these symptoms have occurred at a given time with previous pregnancies. Ask whether they have been observed this time since the patient first noticed the enlargement of the abdomen. Quickening is usually noticed at the end of the sixteenth week of pregnancy. The signs of pregnancy in the later months are Fig. 130. — The Height of the Fundus Uteri at the Various Weeks of Pregnancy (After Zweifel.) softening of the cervix, increased vaginal discharge, ballottement after the twenty-first week. Fluctuation in the uterus is. very indistinct unless the liquor amnii is in excess and the uterine walls are thin from any cause. By careful palpation the intermittent rhythmical contractions of the pregnant uterus may be felt as early as the fourth month. A good deal of patience, gentleness, and skill are necessary to get this sign. Purplish discoloration LARGE OVARIAN TUMORS 307 of the vulva and anterior wall of the vagina are to be made out from the sixth to the twelfth week. If milk or colostrum can be s< raeezei I from the breasts it is an important indication of pregnancy. Fetal heart sounds can be heard after the twentieth week, and fetal movements can be felt after the sixteenth week unless the fetus is dead. The tumor has developed relatively rapidly; there is pigmentation of the areola? of the nipples, and of the linea alba in some cases; edema of the ankles is not uncommon after the \ r^>y<. 9 WL >t^- A Fig. 131.— The Abdomen of Ascites Seen in Profile. (Kelly.) seventh month; the face shows sometimes the fades utcrina, a fullness about the eyes and front of the cheeks. In the case of an ovarian tumor there is no softening of the cervix; the tumor is distinct from the uterus and is of gradual development; there is no ballottemenl and there are no fetal heart sounds or movements; also there is absence of pigmentation of the areolae and the linea alba: edema of the ankles is rare, except after a tumor has existed several years; the superficial veins of the abdomen are enlarged, and the facies ovarina is present in the case of long-existing tumors. Hydramnios, an excess of amniotic fluid, has led many a to diagnose ovarian cyst. A careful study of the hi ymp- toms and signs of pregnancy and ovarian tumor ought to I 308 DIAGNOSIS OF DISEASES OF THE OVARIES differentiation relatively easy and sure. In ovarian cyst the tumor is of less rapid development, there is no ballottement, and the tumor is more on one side than the other, and, most important, it is distinct from the uterus. 2. Ascites. — An accumulation of fluid in the peritoneal cavity may accompany an ovarian tumor, and in such a case the diagnosis is difficult, and may be settled exactly only at the operation under- taken for the removal of the tumor. The following table, taken from Dudley's " Gynecology/' with modifications, gives the points which serve usually to distinguish ascites from ovarian cyst. Ascites. Large Ovarian Cyst 1. Previous history of disease of kidneys, heart, or liver, or peritoneum. 2. Enlargement comparatively sud- den. 3. Face puffy; color waxy; early anemia. 4. With patient in dorsal position symmetrical enlargement of abdomen, bulging in flanks and flat on top. 5. With patient sitting the abdomen bulges below. 6. Navel prominent and thinned. 7. Fluctuation decided and diffuse throughout abdomen, but is absent in the highest parts. Modified on change of position. 8. Intestines float on top of liquid, therefore percussion gives a tympanitic note in the upper portions and flatness in the flanks when patient is on her back. Change in position changes po- sition of intestines and of resonance to the highest part of the abdomen. 9. Vaginal palpation shows bulging into the posterior cul-de-sac. 10. Uterus prolapsed, but size and mobility unchanged. 1. No such history 2. Gradual. 3. Facies ovarina, anemia relatively late. 4. Asymmetrical until tumor is very large, peaked on top. 5. No change. 6. Navel unchanged usually. 7. Less distinct and limited to the cyst. Not modified by change in po- sition of patient. 8. Intestines occupy same position all the time. No change in percussion with change in position of patient, i.e., flat over cyst and resonant above it and to one side, the side opposite to that from which the cyst sprung. 9. No bulging into the cul-de-sac. 10. Uterus displaced by the cyst, mobility limited by the tumor. Encysted ascites, or fluid confined to a limited part of the ab- dominal cavity by adhesions, may give the same areas of dullness and resonance as an ovarian cyst. LARGE OVARIAN TUMORS 3. Fibroids. — There Is considerable danger of confusing a large fibromyoma of the uterus with a large ovarian cyst. The following table, compiled from several authors and from my own experience, points out the chief features in the differential diagnosis: Large Uterine Fibroid. 1. Menorrhagia or metrorrhagia common where the growth is intersti- tial in part. 2. General health not necessarily im- paired, except anemia from loss of blood or debility from pain. Palpita- tion of heart common. 3. Rarely occurs in early life. 4. Slow growth. 5. Apt to be asymmetrical and nodu- lar; tumors commonly multiple. 6. Consistency firm, elastic, or hard. 7. Uterus large and cavity enlarged if growth is interstitial. Tumor a part of uterus or connected by a short and thick pedicle. 8. Uterine bruit by auscultation in half of the cases. 9. No change in facial expression un- less pale from hemorrhage. 10. Superficial veins of abdomen not enlarged. Large Ovarian Cyst. 1. Menstruation unchanged or dimin- ished in amount. 2. General health impaired early. Xo pain except in the case of adhesions, or other complications. Palpitation uncommon. 3. May occur in infancy. 4. More rapid growth. 5. Symmetrical; may be tabulated. 6. Fluctuating. 7. Uterus not enlarged. Tumor con- nected with it only by pedicle, which is apt to be relatively Long. 8. Absent. 9. Fades ovarina and loss of flesh about neck and chest. 10. Veins enlarged. It must not be forgotten that because of degenerative proc- esses in a uterine fibroid there may be fluid in the tumor and fluctuation will be found, and that in sonic of the ovarian tumors with solid contents fluctuation may be absent. As stated before, it is never justifiable to tap a tumor, a procedure once much in vogue for the purpose of diagnosis, because sonic of the fluid is almosi sure to escape into the peritoneal cavity and to cause peritonitis of a grade and severity depending on the character and amount of fluid extravasated. 4. Accumulation of Gas or Fecal Matter in the Intestines. I panites has been mistaken for ovarian cyst. Accumulated gives a tympanitic note on percussion, the gurgling of gas in tin- bowels may be heard by auscultation, and there is an abscm a fluid wave on palpation. By the vaginal tour!, there i 310 DIAGNOSIS OF DISEASES OF THE OVARIES absence of the firm elasticity communicated by a fluid or solid tumor. In the case of fecal accumulation there is a history of chronic constipation and the distended bowel will pit on pressure by abdominal or vaginal touch. Active catharsis removes the tumor. 5. Fat or Tumors in the Abdominal Walls, including "Phantom Tumor." — A thick panniculus adiposus may simulate an ovarian tumor and, strange as it may seem, well-known surgeons have oper- ated for tumor under such conditions. Grasping the abdominal walls in the hands, it is possible in most cases to determine that the fat is in the substance of the wall rather than in the abdominal cavity. Edema of the abdominal walls sometimes simulates Central part of abdomen Tympanitic Fig. 132. — Diagram of a Cross Section of the Abdomen of Ascites, Dorsal Position. tumor. In this case we expect to find pitting on pressure and evidences of edema elsewhere. Tumors of the anterior abdominal walls consist of fibromyoma of the rectus muscle and cysts of the urachus. They are of un- common occurrence. Fibromyoma of the Rectus. — Two instances of this have fallen under my observation. Both patients were twenty-nine years of age and mothers of families. One was seen with Dr. F. W. Johnson, of Bos- ton, in consultation, March 18, 1892, and operated upon by him the same day in my presence. Here there was a tumor of soft consist- ency, the size of a Florida orange, in the left epigastric region. The other was a patient operated upon by me October 23, 1896. In this case there was a somewhat smaller tumor of harder consistency in the right rectus muscle, just below the level of the umbilicus. LARGE OVARIAN TUMORS 311 Both were entirely extraperitoneal and were pronounced by the pathologist to be fibromyoma. Cysts of the urachus develop in the normally impervious cord which runs from the bladder to the umbilicus. Like the bladder itself, a cyst of the urachus represents a persistent portion of the allantois. A cyst as large as the urinary bladder, or Larger, may form in the course of the urachus. Such a cyst is situated between the fascia and the peritoneum on the inside of the abdominal parietes, in the median line. It is to be differentiated from an ovarian cyst by its absence of connection with the uterus or ii- appendages, by the greater area in the abdomen of intestinal Formerly dull, now tympanitic Change in line of tlatiirss Fig. 133. — The Same as Fig. 132, Lateral Position. Showing Change in Situation of Areas of Dullness and Tympany. resonance, and by the absence of the other signs and Bymptoms of ovarian cyst. " Phantom Tumor." — Phantom tumor occurs occasionally in hysterical women who have the power of contracting the muscles of the abdomen so as to form a mass thai simulates an abdominal tumor. The muscular contraction can be overcome sometimes in these cases by firm pressure of the hands and the tumor then disappears. There is exaggerated tympany over the tumor be cause the intestines, held by the muscles, form the tumor. In many cases it is impossible to make an exact diagnosis without etherization, and accordingly it is well to etherize a doubtful of phantom tumor or tumor in the abdominal wall. 6. Cyst of the Pancreas. The situation of the tumor it importance in differentiating cysi of the pancreas from ovarian cyst. The former develops under themarginof the ribe on thelefl 312 DIAGNOSIS OF DISEASES OF THE OVARIES side and grows from above downward. If the cyst is large the liver and stomach may be displaced upward, while the transverse colon is depressed under the tumor, the cyst reaching the pelvis only exceptionally in the case of very large tumors. Therefore a pancreatic cyst can be confused only with high-lying ovarian cyst. Pancreatic cysts generally are thin-walled and the fluid is thin, consequently fluctuation is marked. The greatest convexity of the abdomen is in the neighborhood of the umbilicus. The history given by the patient is that the tumor wTas high up under the ribs when first noticed, and bimanual examination of the pelvic organs shows that there is no connection between the uterus and the tumor and that the ovaries are not enlarged. 7. Tumors of the Spleen, Liver, and Kidneys. — Tumors of the spleen originate, of course, in the left hypochondrium, have an oblique posi- tion, and a peculiar elastic consistency. Under the influence of de- generative processes or the presence of an echinococcus cyst there may be fluid in a splenic tumor. Such a condition must be re- garded as very unusual, however. In tha case of wandering spleen the tumor may be in the iliac fossa, and may be mistaken for an ovarian tumor or a kidney. Careful palpation of such a tumor with the aid of an anesthetic will show one or more notches in the anterior border and perhaps a vertical slit at the hilum. Palpa- tion of the kidney regions will show the presence of the kidneys in their normal situation. It has been suggested by H. A. Kelly (Kelly and Noble, " Gynecology and Abdominal Surgery/' Vol. II., p. 597) that by passing a renal catheter and injecting the kidnej^ with enough fluid to produce a mild renal colic, the pain will be re- ferred to the lumbar region and not to the splenic tumor. Exami- nation of the pelvic organs ought to exclude uterus, tubes, and ovaries from participation in the tumor. A wandering spleen has been known to become lodged in the pelvis and there to obstruct the intestine (case of Korte, cited by J. Bland-Sutton, Brit. Med. Jour., 1897, p. 132), and J. C. Webster (Jour. Amer. Med. Asso., 1903, Vol. XL., p. 887) has reported a case of wandering spleen that occupied the right iliac fossa. Tumors of the liver may be confused with ovarian tumors if they reach downward to the pelvis, or if during late pregnancy an ovarian tumor has become fixed to the liver by adhesions, so that upon involution of the uterus the tumor remains in the upper LARGE OVARIAX TUMORS 313 abdomen. The firm, hard consistency of the liver is more or less characteristic, also its sharp lower border, which is placed obliquely to the ensiform cartilage and is indented with a notch for the gall bladder. Also, all liver tumors move more or less on dee]) respira- tion, except accessory lobes, very large tumors, and echlnococcus disease. The pelvic organs are investigated and the relation of the tumor to the liver tested by moving the tumor about and noticing if the liver is moved also. Tumors of the kidney are not of frequent occurrence. The most common are: hypernephroma and papillary cystoma. Malignant tumors affect especially the young and the old. Hematuria is present in almost all malignant tumors of the kidney; pain in the region of the kidney is a less common symptom. Hypemepk is a tumor arising from adrenal tissue but involving the kidney in practically all instances. The tumor is lobulated and extends toward the median line. It is malignant and has metasti most commonly in the lungs and liver. Polycystic disease of the kidney consists of a cystic degeneration of the kidney parenchyma, and the tumor is like a bunch of grapes. Many of these tumors are congenital. Congenital kidney 6k is apt to be associated with disease of the ovaries, as the two de- velop together in fetal life. Echinococcus cysts develop in the kidney in 5.8 per cent of all cases of hydatid disease. The tumor grows slowly and forms a smooth, round, movable mass. A movable kidney may get as low as the pelvis. Its shape is characteristic. Hydronephrosis may accompany renal tumor and in this case the urine will show abnormal constituents. Cystic tumors or simple cysts of the kidney arise in the outer part of the cortex, and may attain great size. Such a cyst is to be differen- tiated from an ovarian cyst by its location in the flank, its relative immobility, and by its not being connected with the uterine organs as proved by the bimanual examination. If the uterine organs are normal the differentiation is easier than if they are diseased. 8. Cyst of the Omentum.— Cysts of the omentum are mostly flal and shield-shaped; they are very freely movable, and can b tated so that in some cases the posterior portion of the cysl may be palpated. They are of infrequenl occurrence, and h is gener- ally easy to determine that the cyst has no connection with the uterine organs. 314 DIAGNOSIS OF DISEASES OF THE OVARIES 9. Echinococcus Cysts. — Echinococcus disease may be confused with ovarian tumor especially if it involves structures in the pelvis. It has been referred to as occurring in the liver, spleen, and kid- neys. In the pelvis it occurs in the following situations according to Bland-Sutton (" Diseases of Women," Bland-Sutton and Giles, p. 388): (a) The uterus; (b) the mesometrium; (c) the pelvic bones; (d) the omentum; (e) the Fallopian tubes. There is no authentic case on record of primary echinococcus cyst of the ovary. Large tumors may develop in any of the structures named. As a rule, they form part of a general invasion of the subperitoneal tissues. The colonies are apt to communicate with the vagina, bladder, or rectum and the characteristic vesicles escape with the urine or feces. Bland-Sutton says, "The clinical recognition of echinococcus cysts in the pelvic