A Text-book of Diseases of Women

by Charles B. Penrose

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.