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, Aronson25 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 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.
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 Tait26 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.
26 London Obstet. Trans., vol. xxii. p. 97.
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 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.