consistency. In monocysts the fluid is often limpid and colorless. In
multiple cysts the contents are usually syrupy, thick, and turbid.
Sometimes the {302} color is quite dark, as much so as weak coffee. The
surface of the fluid, after standing, will be covered with a pellicle
of cholesterin crystals, which sparkle in the sunlight. In proliferous
cysts the contents are usually viscid, sometimes as much so as jelly,
and to this the term colloid is applied. Foulis, who is an authority on
this subject, states that he has "never found that an ovarian fluid,
however long kept, ever deposited a precipitate spontaneously. Whereas
very frequently in the case of an ascitic fluid such a spontaneous
precipitate appeared within a period varying from a few hours to a few
days."[21] Again he observes: "After ten years of observation made on
fluids withdrawn by the aspirator, I found that ovarian fluids never
throw down a precipitate of a fibrinous character. An ovarian fluid was
always a pure cellular secretion. An ascitic fluid was always the
result of obstruction to the circulation or of inflammatory action in
the peritoneum, and ascitic fluids allowed to stand for a short time
nearly always showed a precipitate with the character of felted
material under the microscope. If they tapped the patient and subjected
the fluid to this test, two or three days would suffice to tell in
cases in which there was doubt. The deposit in ovarian fluids showed
cellular, not fibrinous, elements under the microscope."[22]
[Footnote 21: _Edinburgh Medical Journal_, July, 1885, p. 76.]
[Footnote 22: _Ibid._, June, 1885, p. 1131.]
Chemically, the contents are mucous and albuminous, the albumen being
readily detected by the tests of heat and nitric acid. Microscopically,
ovarian fluid is found to contain fat-globules, epithelial, granular,
and pus-cells, crystals of cholesterin, blood-corpuscles, and compound
granular cells, also called the inflammatory globules of Gluge.
Whether ovarian fluid contains a cell or corpuscle peculiar to itself
is yet a moot question. Drysdale contends that it has a characteristic
cell. He describes it as "an albuminoid body containing little fatty
particles which give it a granular appearance. It resembles in some
particulars many other granular cells, but can be distinguished from
all other cells found in the abdominal cavity.... The principal test I
employ is acetic acid. If the cell is ovarian, the acid changes it but
little, perhaps rendering it only a little more transparent. But if it
be a white blood-cell, a lymph-corpuscle, or any of those granular
cells which resemble them, it will nearly always take on a different
appearance, the cells almost vanishing perhaps, and multiple (2-5)
nuclei appearing, as in the pus-cell. Then, if the cell be suspected to
be fatty, degenerated, or Gluge's cell, ether may be added, by which
the fatty materials will be dissolved and disappear. If no fatty
degeneration be present, it is sufficient to add acetic acid."[23]
Garrigues, on the other hand, contends that the ovarian fluid does not
contain a characteristic cell.[24]
[Footnote 23: _Trans. Amer. Gynæcol. Soc._, vol. i. p. 195.]
[Footnote 24: _Ibid._, vol. vi. p. 54.]
If I am not mistaken, the opinion of the best microscopists of
Philadelphia is that the Drysdale cell, while not characteristic of
ovarian fluids, is not found in any other fluid in such large numbers,
and to that extent it is of diagnostic value.
CAUSATION.--In probably the very great majority of cases an ovarian
cyst is a dropsy of several ovisacs, but the cause of such growths has
never yet been ascertained. In the majority of cases it seems to depend
upon some sexual disturbance.
Very recently the relation of the sexual condition to disease has been
{303} made the subject of scientific inquiry. From a careful
examination of the registrar's tables for France, M. Bertillon shows
that marriage, by giving a comparative immunity from diseases of the
sexual organs, prolongs life in both sexes. This statement is confirmed
by the statistics of ovarian tumor. Of Lee's 136 cases, 88 were
married, 37 were unmarried, and 11 were widows. Of Sir Spencer Wells's
first 500 cases, 260 were married, 221 were unmarried, and 19 were
widows. Out of 155 completed cases of ovariotomy performed by myself,
91 were married, 48 were single, 16 were widows. Of the married, 24
were sterile, 10 had one child, and 26 had but two children, and
several confessed to using preventive measures. Out of a total of 791
cases of ovarian tumor, there are, then, 352 without husbands to 439
with husbands. Now, when one considers how small the proportion of
single women and of widows is to married women whose husbands are
living, the significance of these figures goes to show that
childbearing women, and especially the prolific ones, are less liable
to cystic degeneration of the ovaries, and that, unless the cycle of
reproduction is completed in a woman, she is plainly violating some law
of her being.
SYMPTOMS.--There are no symptoms pathognomonic of this affection, for
they are mainly those of pressure, and therefore belong in common to
all fluid collections in the abdominal cavity. But in proportion as the
abdomen swells there is a marked emaciation of the extremities. The
limbs waste away, the face becomes pinched, the eyes are hollow and
staring, deep wrinkles and furrows appear on the forehead and around
the mouth, and the nostrils are wide open. This facial expression is
termed the facies ovariana. Sometimes, when both ovaries are
simultaneously affected, hair will grow on the chin and on the upper
lip.
THE NATURAL HISTORY.--The natural course of an ovarian cyst is to grow
rapidly, and in about two years from the time of its discovery to
destroy life by exhaustion through the embarrassing pressure which it
makes upon the organs of respiration, circulation, and nutrition.
Malignant cysts grow more rapidly than the benign, while the latter
will, on the other hand, occasionally remain for years in a state of
quiescence. I have kept stationary cysts under observation for ten
years, and others have been reported which lasted twenty years without
change.
As a cyst develops it is very likely to contract adhesions to the
organs with which it lies in contact. The most common adhesion is that
of the omentum. Next to this is adhesion to the abdominal walls. Then
will happen more rarely adhesions to the bowels, womb, bladder, pelvis,
liver, and stomach. A loop of intestine will sometimes be found
fastened to the front wall of the cyst, but usually the bowels lie
packed behind the tumor.
Rupture of the cyst sometimes takes place, either spontaneously,
through over-distension, or through violence, as a kick, a rude fall,
or from being run over by a carriage. This accident, if the fluid
happens to be bland, may be followed by a cure; but more often a
violent peritonitis sets in, which carries the patient off in a few
hours. From a study of 257 cases, Aronson[25] rates the fatality at 41
per cent.; but without question the very great majority of cases of
bursting cysts of the abdomen in which this accident was followed by a
cure were cysts of the parovarium, which being {304} thin-walled are
likely to burst, and which contain a bland, unirritating fluid.
Bursting of the sac can be recognized by more or by less collapse and
pain, by the disappearance of the cyst, and by the lessened size of the
abdomen. If the patient does not at once succumb, excessive diuresis
usually occurs.
[Footnote 25: _American Journal of Obstetrics_, Nov., 1883, p. 1210.]
It happens occasionally that the inner cyst-wall inflames, either
spontaneously or in consequence of being tapped or from other injury.
Suppuration then takes place, the contained fluid becomes fetid, and
offensive gases are generated which give a tympanitic sound on
percussion. There will be creeping chills, a red tongue, night-sweats,
a frequent pulse, a general rise in the temperature with evening
exacerbations: in one word, all the well-known symptoms of
blood-poisoning will be present in a greater or less degree. Unless the
cyst be at once removed the woman will speedily die.
Ulceration of the cyst, with perforation of its wall, may also occur.
The decomposing contents will then be discharged, either into the
peritoneal cavity or into any viscus to which the cyst may have
contracted adhesions. In this way the purulent contents of an ovarian
cyst have been discharged through the bowels, the bladder, the vagina,
and even into the womb through the oviducts.
Hemorrhage within the sac is an occasional accident. When it takes
place the tumor rapidly enlarges, great abdominal pain is caused by
this sudden stretching, the complexion grows pale, the features become
pinched; there will be collapse and all the symptoms of internal
hemorrhage. If the bleeding does not stop, the patient will die in a
few hours. On the other hand, if she survives the immediate danger, she
is liable to succumb later to septicæmia, which arises from the
decomposition of the now bloody fluid. The immediate removal of the
cyst gives the woman, then, her sole chance of life.
Twisting of the pedicle of an ovarian tumor by axial rotation is
another serious complication, which leads to its strangulation and
gangrene, with consequent fatal peritonitis. The chief factors of this
accident are, probably, the filling and emptying of the bladder and
rectum, which may rotate an unadherent cyst with a long stalk. The
symptoms of axial rotation, as carefully noted by Tait[26] and
Aronson,[27] are sudden accession of severe abdominal pain and
tenderness, a rapid increase in size, and incessant vomiting, the
matter thrown up soon becoming green. The pulse rises, but the
temperature is not always affected, and rigors are absent. Such a train
of symptoms should lead at once to the abdominal section.
[Footnote 26: _London Obstet. Trans._, vol. xxii. p. 97.]
[Footnote 27: _American Journal of Obstet._, Nov., 1883, p. 1211.]
DIAGNOSIS.--The diagnosis of ovarian cysts is often beset with so many
difficulties that very humiliating blunders have been made by the best
surgeons of the day. Lizars of Edinburgh performed laparotomy on a
woman in order to remove a suspected ovarian cyst, and found nothing
but fat. Others have done the same thing, and to their dismay have
discovered merely an accumulation of wind in the intestines. The great
Dieffenbach once opened the belly of a woman for supposed extra-uterine
pregnancy, and found neither fat nor wind--not even, indeed, a trace of
a tumor. Once an enormously distended bag of waters {305} broke just as
a deservedly eminent British surgeon had rolled up his sleeves and was
about to wheel his patient into an amphitheatre crowded with spectators
to witness an ovariotomy. A surgeon of whom Great Britain can well be
proud once drove his trocar into the shoulder of a foetus under the
idea that he was tapping one of these cysts. These facts show the
importance of knowing how to make an examination for a suspected
ovarian cyst, and how to distinguish such a cyst from other tumors and
other fluid collections in the abdominal cavity.
The usual history of an ovarian cyst is--a tumor first discovered in
one groin, rapidly enlarging, without tenderness or soreness, giving no
inconvenience save from its bulk. The general health remains good until
the tumor begins to distend the abdomen; then emaciation takes place,
the strength becomes impaired, and the features begin to assume that
pinched expression described on a preceding page as the facies
ovariana. By inspection and palpation there will be found an elastic
but somewhat irregular tumor, yielding the sense of fluctuation. By
percussion a dull sound will be elicited at every point, except in the
flanks, which are more or less resonant. If the contents of the tumor
are colloid or the tumor is thick-walled or very tense, the sense of
fluctuation may be either obscure or wanting. Sometimes a feeling like
that of fluctuation is conveyed by a fat-laden wall of the abdomen. To
muffle this fat-thrill the ulnar edge of the hand of an assistant is
laid along the linea alba while the surgeon percusses the abdomen. The
pressure thus exerted acts precisely like the damper-wedge of the
piano-tuner, which muffles the sound of one string while its fellow is
being tuned. By these means fluctuation can be detected and the
diagnosis of a collection of fluid unhesitatingly made out.
By the amount of solid and fluid portions of a cyst correct diagnosis
can often be made out, whether it is simple or multiple, compound or
proliferous; but this is a matter of comparatively little practical
importance, because when once a growing tumor has been ascertained to
be ovarian, its removal must follow as a matter of course.
There are, however, certain enlargements or tumors of the abdomen which
are very liable to be mistaken for an ovarian cyst, and to these, in
the order of their frequency, we shall call attention.
Ascites.--When the fluid is not encysted, but free, as in ascites, it
is at liberty to go to the most dependent portions of the body. Hence
changes in the posture of the woman will make corresponding changes in
the level of the fluid. These level-changes are made evident by
percussion. When the woman lies on her back the intestines float up to
the surface, and the fluid gravitates to the flanks, making them bulge.
In other words, percussion in the dorsal position elicits a clear note
in the umbilical region and a dull note in each flank. In this posture
the front surface of the abdomen is symmetrical and somewhat flattened.
But when the woman sits up the belly becomes convex. Further, ascitic
fluid is displaceable by pressure on the abdomen. But even these signs
are not always trustworthy, because the intestines, glued down by
adhesions, may not float up, and there will be dulness over the front
of the abdomen, or a distended colon may make each flank resonant. For
instance, I have known a papillary cancer of the omentum attended with
dropsy of the abdominal cavity to give such signs of ovarian cyst as
dulness in front and resonance {306} in the flanks. When the fluid is
ascitic the floating or false ribs are not pushed outward. The womb is
usually low down and movable; there will also be more or less of
bulging in Douglas's pouch.
On the other hand, in an ovarian cyst the womb is usually not very
movable, and it is displaced to one side, generally behind the cyst.
While the woman lies on her back the front surface of the abdomen is
convex and unchanged in form. The floating ribs bulge out, making the
chest conical. There will also be dulness in the front wall over the
tumor, but usually more or less resonance in the flanks and over the
region of the stomach: this clearness on percussion has been aptly
termed coronal resonance. These areas of dulness and of resonance
remain constant whatever the posture of the woman. Yet in suppurating
cysts or after a careless tapping, or in cysts communicating with the
intestine, the sac may contain gas, which will give a tympanitic sound
over all the elevated portions of the abdominal surface.
It must, however, be borne in mind that ascites may exist concurrently
with an ovarian cyst, and especially if the tumor be malignant in
character. This can usually be detected by deep palpation, when the
cyst will be reached and recognized by the fingers; or by pressing
lightly, and then more firmly during percussion, an upper and a lower
stratum of fluctuation will be detected.
Pregnancy.--The question of pregnancy is a very serious one, for it is
sometimes a most difficult one to decide, especially when dropsy of the
amnion (hydramnios) exists. In making a diagnosis nothing must be taken
for granted, not even the woman's statement. She may be mistaken, or,
indeed, she may be wilfully deceiving in the hope of having a cheap
abortion induced by the examination. She may be pregnant and yet
menstruate. On the other hand, an ovarian tumor will sometimes arrest
menstruation. A healthy, ruddy complexion coexistent with abdominal
enlargement should always excite a suspicion of pregnancy. There is
sometimes a jaded look in pregnancy--the facies uterina--but never the
facies ovariana.
The various signs of pregnancy should be searched for, especially
ballottement and the foetal heart-sounds. The cervical region should be
most carefully examined per vaginam. A good broad rule to remember is,
that when the womb is gravid the cervix is as soft as one's lips; when
it is empty the cervix is as hard as the tip of one's nose. In all
doubtful cases any operation should be postponed until time has
revealed the true condition of things. Of course the introduction of
the sound will settle the question of pregnancy, but this procedure is
not to be thought of when any doubt exists, and it is therefore useless
as a diagnostic agent. An ovarian tumor may coexist with pregnancy, and
may have to be tapped or be extirpated before the delivery of the
woman. The history of the case, the unusual size of the abdomen, the
sulcus between the two tumors, will generally reveal the condition.
Fibroid Tumors of the Womb.--These tumors often reach a very large
size, and if of the soft variety give an obscure sense of fluctuation
which so closely resembles that of a colloid ovarian cyst or of a tense
thick-walled cyst as to make the differential diagnosis very puzzling.
The hard myoma gives no sense of fluctuation, but, on the other hand,
if pedunculated it can be very readily taken for a solid ovarian tumor.
A {307} fibroid tumor of the womb can very generally be told by the
history of menorrhagia, by its slow growth, by the uterine souffles and
colics, by the effacement of the cervix, and by the tumor being felt to
be continuous with the cervix and inseparable from the womb. Then,
again, women burdened with a fibroid tumor so far from losing flesh
usually become more fat, and their complexion, like that of many
pregnant women, is mottled with patches of brown pigment. Further, the
uterine cavity is usually much longer than natural, and when the tumor
is moved from side to side the motion is communicated to the sound
passed within the cavity. But every rule has its exceptions, for when
an ovarian cyst has a close attachment to the womb the latter may
become elongated and also follow the movements communicated to the
tumor.
The positive diagnosis between an ovarian cyst and a fibro-cystic tumor
of the womb is impossible, but, fortunately, the latter disease is
exceedingly rare. The existence of the latter may be inferred if the
woman's face has a jaded appearance and is disfigured by brown
patches--the facies uterina--if the growth of the tumor has been very
slow, and if the womb is implicated with it. After tapping there will
be a partial collapse of the tumor, and the fluid withdrawn is usually
bloody and it coagulates on being cooled. After an exploratory incision
the tumor presents to the eye a dark-blue and vascular capsule covered
with interlacing fibrous bands.
Renal Cysts.--Cysts of the kidney are very commonly mistaken for
ovarian cysts. I have made this mistake, and it was not until after
breaking up adhesions and emptying the cyst that I discovered the
character of the tumor. It was successfully removed. Renal cysts start
from below the floating ribs and extend downward and forward, while an
ovarian cyst begins from below and grows upward. The former, being
generally caused by impaction of a calculus in the ureter, are usually
associated with urinary disturbances. They also push the intestines
before them, which give a resonant sound on percussion, while the
contrary holds good with an ovarian cyst. Since the transverse colon
lies between the cyst and the liver, the line of resonance caused by it
will show that the cyst is not hepatic. The fluid withdrawn from a
renal cyst contains urea and the other constituents of urine, but the
urinous odor will be either very faint, or, as in my case, wholly
absent. It may as well be stated here that when renal cysts present
great difficulties in the way of their removal, they had better be
treated by a large drainage-tube.
A floating kidney may be mistaken for a small ovarian tumor. But the
latter has a pelvic attachment and can readily be pushed down into the
basin, while the former is kept from being pushed very low downward by
an upper attachment. Again, the floating kidney usually keeps its
peculiar shape, and it is frequently lost by slipping from under the
fingers into its natural bed in the flank.
Spina Bifida.--Strange as it may seem, this spinal cyst, when internal
on account of a deficiency in the anterior parietes of the lower
vertebræ, has been mistaken for an ovarian or a parovarian cyst. I am
cognizant of two such errors of diagnosis made by two distinguished
gynecologists. In each the sac was emptied by the aspirator, and the
patient perished shortly afterward with the same kind of cerebral
symptoms which follow the sudden withdrawal of the fluid from the
cavity of an external spina bifida.
{308} Phantom Tumors.--In the diagnosis of an ovarian cyst one must be
on guard not to mistake for it a phantom tumor. In this imaginary kind
of tumor, which hysterical women have the knack of creating, the whole
belly will be uniformly distended to the size of the gravid womb at
term. This is caused partly by flatus and fat, and partly by the
arching forward of the spinal column, with the recti muscles drawn so
tense that they cannot be indented. I have frequently had patients with
this kind of abdominal enlargement sent to me from a distance, under
the impression that it was due to some kind of tumor. But the diagnosis
is easily made from the uniform resonance all over the belly; if,
moreover, the patient's attention be engaged by conversation, the
rigidity of the recti muscles disappears, the abdomen becomes flaccid,
and the hand can be made to sink in so as to feel the spine. In very
nervous women it may be needful to administer an anæsthetic, when all
the tokens of a tumor will promptly disappear.
Obesity.--A large accumulation of fat on the abdominal wall and in the
omentum has frequently given rise to the suspicion of the existence of
an ovarian cyst. This condition occurs, usually, at the climacteric,
and on percussion the vibratile thrill of the fat-laden wall of the
abdomen conveys a very misleading impression of fluctuation. Further,
to add to the difficulty, if the layer of fat be a very thick one, the
abdomen, instead of being resonant on percussion, yields a dull note.
But in obesity the fat is not limited to the abdomen, for the breasts,
face, and limbs partake of the general enlargement. The abdominal wall
hangs in folds when the sitting posture is assumed, and the umbilicus
is indented and not protuberant. My own method of making the diagnosis
is to grasp the abdominal wall with both hands and ascertain the amount
of fat. When this amount is excluded, there will not be found room
enough behind it for a tumor of any size, and the enlargement will thus
be satisfactorily accounted for.
A dilated stomach, cystic tumors of the omentum, and encysted abscesses
of the peritoneal cavity, and, indeed, of the abdominal wall, have been
mistaken for ovarian tumors; but these are very exceptional cases. In
all doubtful cases an exploratory incision should be resorted to.
SURGICAL TREATMENT OF OVARIAN CYSTS.--In the consideration of this
subject it may be divided into the palliative treatment and the radical
treatment.