A Text-book of Diseases of Women

by Charles B. Penrose

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.

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