NATURAL HISTORY AND TREATMENT OF OVARIAN CYSTS.
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.
SECONDARY CHANGES OR ACCIDENTS 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 in about 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 symptoms immediately 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 called _myxoma 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 CLINICAL HISTORY OF OVARIAN CYSTS.
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 pathological condition 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 papillomatous tumors, 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 the _facies 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 the tumor. 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 dermoid cyst 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 to exclude 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 tumor_ is a rare condition. A woman imagines that 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.
TREATMENT OF OVARIAN CYSTS.
=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 several years 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 can be 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.