CHAPTER XVII THE DIAGNOSIS OF DISEASES OF THE OVARIES (Part 4)

organs, mesometrium, or bones is sometimes made by a sort of ' lucky guess ' when other and more common diseases can with certainty be excluded. Occasionally when a patient seeks advice for pelvic trouble, and brings ' vesicles ' which have escaped by the rectum, vagina, or urethra, much speculation is spared. When the bones are eroded and swellings form under the skin, they are punctured, and characteristic fluid with vesicles and hooklets escapes, and so the diagnosis is established. When the cysts suppurate the physical signs are those of abscess." 10. Dilated Stomach. — Careful percussion of the stomach area, auscultation of the abdomen while the patient swallows a mouth- ful of water, the appreciation of a gurgling sound all over the region occupied by the stomach, and the situation of the maximum of enlargement of the abdomen above the umbilicus, ought to deter- mine the presence of a dilated stomach. If there is a doubt ad- minister an effervescent mixture and practice percussion when the stomach is distended with gas. 11. Distended Urinary Bladder. — The bladder may rise as high as the umbilicus when overdistended and may present the appear- ance of an ovarian cyst. (See Fig. 85, page 217.) The bladder tumor is in the median line, close held to the back of the arch of the pubes; it bulges into the vagina, distending the anterior wall; there is almost continuous overflow of urine, and generally hypo- gastric distress, except where the patient is unconscious or the distention has existed a long time. Passing the catheter removes all doubt. COMPLICATIONS OF OVARIAN TUMORS :',!." Diagnosis of the Complications of Ovarian Tumors The complications to which ovarian tumors arc subject arc: 1. Adhesions and incarceration. 2. Intraligamentous development. 3. Torsion of the pedicle. 4. Infection and suppuration. 5. Degenerative processes, including malignancy. 6. Rupture. 7. Association with pregnane}-. i. Adhesions and Incarceration. — Adhesions between an ovarian tumor and its surrounding structures make the diagnosis much more difficult, especially in the case of small ovarian tumors, those lying wholly within the cavity of the pelvis. The history of at- tacks of inflammation may give a clew to the presence of adhesions, as the occurrence of pain. It is a well-known fact that the parietal peritoneum rather than the visceral peritoneum is the seat of pain. This fact has been demonstrated during abdominal opera- tions performed under local anesthesia. Therefore we should expect adhesions to the parietal peritoneum to cause more pain than those to the viscera. Extensive adhesions may occur with- out any pain whatsoever. Fixation of a tumor to a greater or less degree indicates adhesions as a rule. The exception is the rare condition of incarceration without adhesions. A tumor may become incarcerated in the pelvis, thus causing obstruction of the bowel, or abortion as in the case of the retroflexed pregnant uterus. An attempt should be made to dislodge an ovarian tumor fixed in the pelvis, by putting the patient in the knee-chesl position, letting air into the vagina by means of the Sims speculum, and h\ making traction on the cervix with a tenaculum. Upward pressure on the tumor, the patient being in the dorsal position, through either the vagina or rectum will, in many can-, dislodge a non- adherent tumor. After reposition the bimanual palpation .-in. I the mapping out of the pedicle proceed with greater facility. Some- times the shape and character of adhesions in the pelvis can !><• made out by touch, also adhesions to the abdominal walls in the case of large tumors can be determined in a smaller proportion of 316 DIAGNOSIS OF DISEASES OF THE OVARIES cases. Adhesions to the intestines, omentum, liver, or spleen can not be diagnosed with certainty. 2. Intraligamentous Development. — If a tumor has grown between the layers of the broad ligament it is immovable and can not be displaced into the abdominal cavity by bimanual manipulation. It gives the impression of being closely united with the uterus and the examiner may receive the impression that he has to do with a fibroid tumor of the uterus. Intraligamentous tumors are gen- erally cystic, however; they have no pedicle and sometimes may be differentiated from parovarian cysts by this characteristic. If the physician can decide that an immovable cystic tumor in the pelvis is connected not only with the uterus but with the side ml ligament7' Fig. 134. — Diagram Showing the Course of the Utero-sacral Ligaments in the Case of a Retro-peritoneal Tumor. of the uterus the tumor is probably an intraligamentous ovarian cyst. This may be done sometimes by grasping the uterus and palpating it separately from the tumor. The uterus is commonly displaced laterally to the side of the pelvis opposite to that occupied by the tumor. Occasionally the ovary with its long Fallopian tube stretching to it as a cord may be made out lying on the top of the tumor, and now and then the round ligament can be palpated as a round cord coming over the surface of the tumor to the internal abdominal ring. To distinguish a tumor developing under the peritoneum in the back of the pelvis from an intraligamentous tumor one tries to palpate the utero-sacral ligaments. If these are in front of the tumor it is a retro-peritoneal growth, whereas if the ligaments COMPLICATIONS OF OVARIAN TUMORS 317 are behind the tumor it is an intraligamentous neoplasm. Figs. 134 and 135.) 3. Torsion of the Pedicle. — Rotation of an ovarian tumor on it- long axis causing twisting of its pedicle is by no means an uncom- mon happening. It presupposes the absence of adhesion- to sur- rounding fixed structures such as the pelvic walls or the parietes of the abdomen. It is more apt to occur in tumors of medium size. To detect a twisting by palpation of the pedicle where all the con- ditions are most favorable is a possibility. Ordinarily torsion is diagnosed only by its results. The twisting may be gradual, in which case the tumor adjusts itself to the lessened blood supply caused by the constriction of its pedicle, or it may be rapid. Urej-0-sa.ctrd -/-Uterus. Fig. 135. — Diagram Showing the Course of the Utero-sacral Ligaments in tb Case of an Intra-ligamentous Tin nor. Whether gradual or rapid there comes a lime when the blood supply is cut off, then ensue in the cyst edema, enlargement, suppuration, or even gangrene. Atrophy has been known to occur in the case of very small tumors and complete separatiou of the cysl from it- pedicle in rare instances. Torsion is apt to be followed by adhe- sions, especially adhesions to the bowels. Symptoms of the chronic stage of torsion may be entirely want ing, or a patient may complain of pains in the abdomen especially at the time of the catamenia when congestion of the pelvic organs is normally greatest . These pain- may be associated with nausea and vomiting and are apt to follow viol, nt exertion or trauma. U the twisting is sufficient to cause blood stasis the symptoms are those of general peritonitis and there is present an acute abdominal 318 DIAGNOSIS OF DISEASES OF THE OVARIES emergency. Acute abdominal pain, rapid, feeble pulse, vomiting, elevation of temperature, and a rigid abdomen occurring in a woman known to have an ovarian tumor are symptoms calling for im- mediate operation. Twisting of a pedicle of an ovarian tumor has been mistaken for appendicitis. Bimanual examination will reveal the presence of the ovarian tumor; the pain caused by torsion is not of the colicky character of the pain of appendicitis. Finally the history reveals no similar attacks of pain and no history of digestive disturbances and irregularity of the bowels as in the case of appendicitis. 4. Infection and Suppuration. — Infection of ovarian tumors with streptococcus, typhoid bacillus, or bacterium coli communis, is transmitted by the blood current, or from the intestine, urinary bladder, or the Fallopian tube. Formerly, when it was the custom to tap ovarian cystomata, infection was introduced very frequently in this way. Ovarian cysts become infected following an attack of typhoid fever, and in this case the bacilli, in all probability, gain entrance through the blood. A patient known to have an ovarian cyst should be watched carefully for evidence of infection of the cyst following an attack of typhoid fever. The symptoms are chills, elevation of temperature, rapid pulse, pain, and tenderness in the abdomen. The Fallopian tube is a very frequent carrier of infection to an ovarian tumor. This is to be inferred because it is about the fimbriated end of the Fallopian tube that the densest adhesions are to be found during operation for the removal of infected cysts. It is probable that infection following puerperal fever reaches a tumor by this channel. In the case of an inflamed bladder or in- testine or vermiform appendix the organ may become adherent to a tumor and the inflammatory process be carried to the growth by continuity. The inflammatory process, however transmitted, may go on to suppuration. In this case there are to be noted sudden enlargement of the cyst, severe pain and tenderness, rapid and weak pulse, and chills, high temperature, and exhaustion. Prompt operation alone will prevent rupture or general peritonitis and death. Gas may be formed in the cyst and then a tympanitic note will be given to the percussion over it. 5. Degenerative Processes Including Malignancy. — The following secondary changes may take place in an ovarian tumor, although COMPLICATIONS OF OVARIAN TUMORS 319 none of them can be diagnosed with certainty. On account Of the necessity of speedy operation indications of malignancy require special attention, however. (a) Calcareous degeneration. (b) Fatty degeneration. (c) Myxomatous degeneration. (d) Changes in the fluid contents from straw color — with specific gravity of from 1010 to 1050 — to thick or semisolid, of various colors and consistencies. (e) Malignant degeneration. Carcinoma, sarcoma, endothe- lioma, and teratoma are the malignant processes affecting ovarian tumors. Suspicion of malignity attaches to double-sided tumors, i.e., tumors of both ovaries, and to partial development in the broad ligament. Ascites is common in the case of malignant tumors, and is apt to be small in amount except in the late stages of the disease. Malignant tumors, except sarcoma, are most apt to occur in old rather than in young women, and cachexia is found in the later stages only. Early edema of the legs in the case of small tumors is said to be a sign of malignancy. When the disease has attacked the surface of the tumor hardness of the tissues and a nodular feeling by both abdominal and vaginal palpation is most characteristic. The nodules or lumps may be large or small. The surface is irregular. It should not be forgotten that cancer of the ovaries is very often metastatic and that the primary seat of the disease should be sought in the stomach or intestine. 6. Rupture. — Rupture of an ovarian cyst is of unusual occurrence, especially in these days of relatively early operation on women who have tumors. In the older, preaseptie days, when the danger of operation wras great, many cysts ruptured and filled again or caused peritonitis as it happened. The physician and also the nurse should remember that a thin-walled cysl or one having weak places in its walls because of degenerative processes may be rup- tured by a too vigorous bimanual examination or by preparations for an abdominal operation. Both of these accidents have occurred in my experience. In the case of a multilocular cysl only one loculus may rupture and the rupture may be into the main cavity, into another loculus, or into any one of the following struc- tures: peritoneal cavity -mosl frequenl ami bladder, vagina, or rectum. Rarely rupture has occurred into the -mall intestine, or 320 DIAGNOSIS OF DISEASES OF THE OVARIES Fallopian tube, and very rarely through the abdominal wall or into the stomach. The causes of rupture are, degenerations of the cyst wall; papillomatous growths penetrating the wall; torsion of the pedicle, causing hemorrhage or suppuration in the cyst with in- creased tension ; and trauma, such as blows on the abdomen, care- less handling, already referred to, or contractions of the abdominal walls in labor. Parovarian cysts when once ruptured may not refill. In the case of ovarian cysts the wall continues to secrete fluid after rupture and the cyst may refill or the fluid may be poured into the organ into which the opening has been made. If the fluid is clear and serous it may cause little irritation of the peritoneum; if, on the other hand, it is colloid or dermoid in char- acter it is apt to- set up a lively peritonitis. The gravity of rupture depends then, in large measure, on the character of the cyst con- tents. This being unknown, the complication must be regarded as serious and treated by immediate operation, for rupture of an infected cyst into the peritoneal cavity is usually fatal. The symptoms are severe pain in the abdomen, faintness, rapid pulse, perhaps subnormal temperature. Examination shows ab- sence of the tumor and free fluid in the peritoneum, or discharge of fluid from bladder, vagina, or rectum, or other viscus. If only one loculus has been ruptured the tumor will be diminished in size only by so much. 7. Association with Pregnancy. — Small or medium-sized tumors are more often found in association with pregnancy. Because of the danger of rupture and torsion of the pedicle, the diagnosis of pregnancy in these cases is of the greatest importance. In the early months it is a question of determining the presence of more than one growth in the pelvis or a tumor on each side, one being the uterus and the other the ovarian tumor. The signs of pregnancy are referred to in Chapter XXII., p. 420. If physicians would make it a rule to examine all pregnant women under their care from time to time with reference to the detection of tumors and other abnormalities, many of the tragedies of the puerperium would be avoided. In cases of doubt it is advisable to administer ether in order to make a diagnosis. PATHOLOGICAL VARIETIES OF OVARIAN TUMORS 321 Diagnosis of the Different Pathological Varieties of Ovarian Tumors The different kinds of ovarian tumors according to their patho- logical characteristics are shown in the list on page 291. Prognosis and treatment depend in a measure on the kind of tumor present ; therefore, certain probabilities may be stated as to the different tumors. The following description is taken with few changes from Winter's " Gynaekologischen Diagnostik," p. 303. i. Follicular cysts never occur larger than a base-ball. They arc unilocular, have thin walls, and are not tightly distended, so thai fluctuation can be elicited easily. They are generally unilateral and do not cause pain. 2. Cysts of the corpus luteum arc not larger than a base-ball; they have thick walls, and are unilateral. 3. Simple cysts have thin walls and thin fluid contents, and a it- differentiated clinically from follicular cysts only by their greater size. 4. Multilocular cysts are the most common kind of ovarian tumors. They vary in size from very small to enormous. In the beginning such a tumor is round, but becomes irregular in shape by the development of several cysts within the parent cyst. There- fore, the surface becomes lobulated and in some cases the large and small daughter cysts can be palpated. The consistency varies according to the fluid contents. Hard portions are apt to be found in the walls where there lias been no cystic degeneration. The small or multilocular tumors an; fairly movable; the larger ones are limited in motion by adhesions, which are common, especially to the omentum, bowel, and abdominal wall, seldom to the uterus or other pelvic organs. These tumors are usually uni- lateral and have a well-marked pedicle. Ascites is generally absenl : when present it is in small amount. 5. Proliferating papillary cysts are seldom larger than a man's head. They are not often perfectly round in shape and have an uneven, lumpy surface. In the situations where the papillary masses occur the consistency is not so fluid as elsewhere, fne tumors are apt to affect both ovaries double tumor: they are ol intraligamentous development, at leasl on one side, and arc - 21 322 DIAGNOSIS OF DISEASES OF THE OVARIES partially, but not entirely, in the broad ligament. When the papillary masses have pierced the wall of the tumor there are metastases in different parts of the abdomen, especially in Doug- las' cul-de-sac. Ascites is common. 6. Primary carcinoma, when small, retains the form of the ovary; when large, the tumor has a surface that is very rough because of knobs and excrescences. Small tumors are hard, large ones are cystic because of degenerative processes inside. The pedicle is for the most part short, and the tumor may be intraligamentous. The tumors are generally double and ascites is commonly present. Early edema of the legs is to be looked for in the case of small tumors, and cachexia in the late stages. Metastases occur early. Secondary carcinoma attacking a cyst has the same characteristics. 7. Dermoids are seldom larger than a man's head and most often between a hen's egg and a Florida orange in size. They are round and oval in shape and are seldom double, having for contents thick fluid, fat, bone, and hair ; fluctuation is not marked. Some- times bone may be felt in the wall of the cyst, and often there are portions of solid tissue in dermoid cysts. These cysts are of slow development and occur most often in young persons. Adhesions are common and occasionally the tumor adheres so closely to the intestine that there is gas in the tumor. The x-rays may show the bone in a tumor. 8. Teratomata are apt