A system of practical medicine. By American authors. Vol. 4

by Unknown

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 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 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.