Ovarian cyst

“ When the stroma is chiefly attacked, the ovary becomes hard and rugous; when the follicles are diseased, they increase in size, and one or two of them are usually found to be distended into miniature cysts. There are indeed good reasons for the opinion that an ovarian cyst is a dropsy of many ovisacs, and is caused by ovaritis. The left ovary is the one more commonly affected—a fact accounted for by the pressure of the distended rectum and by the emptying of the left ovarian vein into the renal vein instead of into the vena cava, which is the course of the ovarian vein on the right side. ”

“ In a large number of instances in which operations have been undertaken when fibroids complicate pregnancy, they have been performed on an erroneous diagnosis. The tumours when small and placed laterally simulate ovarian cysts; when large and lying high in the abdomen they have been mistaken for renal tumours, and when low in the pelvis they have been regarded as incarcerated ovarian cysts. The variety of fibroid most likely to lead to operation, under the impression that it is an ovarian cyst, is an interstitial fibroid which becomes painful in consequence of undergoing red degeneration. ”

“ It is called the intra-ligamentous cyst, and needs careful and tedious enucleation for its removal. Sometimes, indeed, extirpation is out of the question, and the cyst has to be treated by the drainage-tube, as will hereafter be shown.
The contents of ovarian cysts vary very greatly in color and in consistency. In monocysts the fluid is often limpid and colorless. In multiple cysts the contents are usually syrupy, thick, and turbid. Sometimes the [p. 302] color is quite dark, as much so as weak coffee. ”

“ 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. ”

“ In a typical case, when the peritoneum is opened the surgeon at once recognizes the bluish-grey glistening surface of the ovarian cyst, and gently sweeps his hand over it in order to ascertain its relations and to learn whether the cyst wall be free from adhesions. It is of the utmost importance to be satisfied as to the nature of the tumour, especially when the operator follows the unsatisfactory practice of tapping, for if he plunge a trocar into a uterine tumour, or into a pregnant uterus, he will involve himself in anxious difficulty. ”

“ Again, when an ovarian cyst is complicated with pregnancy it is best to perform the operation in the first half of the period of gestation; for in the last half the broad ligaments receive a large supply of blood, and all the pelvic vessels become varicose. Pregnancy is indeed no bar to the operation, the prognosis being favorable both to the mother and to the child. Schroeder and Olshausen performed 21 ovariotomies in pregnant women, with only 2 deaths.47 ”

“ 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 387 that she is suffering from a tumor and that her abdomen is increasing in size. ”

“ They also grow more slowly than the ovarian cyst, and do not exert the same profound constitutional impression. The facies ovariana is absent, and the health of the woman may in no wise be disturbed. They, indeed, in the majority of cases, seem to do no harm, and are merely annoying from their bulk. The fluid they contain is with rare exceptions as limpid and clear as spring-water, but with refractive powers so high as to magnify the fibres of the wooden pail into which it has been drawn off. ”

“ Cullingworth reports the history of a woman in whom both ovaries were apparently involved by dermoids, who had given birth to 12 children and had three miscarriages—the last, three months before the removal of the growths. The accompanying illustration, taken from Baldy, pictures a dermoid cyst of the complicated variety laid open and exposing the contents in situ. Mears of Philadelphia reports a case of ovarian cyst removed from a girl of six and a half by Bradford of Kentucky in 1875. From this age on to adult life many similar cases are recorded. ”

“ Occasionally the passage of a fœtus is barred by tumours growing from the uterus, especially a large cervix fibroid, or a fibroid growing from the lower segment of the uterine wall. An ovarian cyst, especially a dermoid incarcerated by the uterus, may render this operation necessary. The rarest causes are cancer of the neck of the uterus and cancer of the rectum. ”

“ Subsequently the peritoneum was found dotted over with minute nodules furnished with tufts of hair growing among the visceral adhesions. When a woman with an ovarian cyst contracts typhoid fever, the cyst may become filled with pus which contains the bacillus typhosus. Such a case occurred in my practice in 1907.
For many years I have abandoned the use of clumsy trocars of all kinds and remove the tumour entire, although it may require an incision from the ensiform cartilage to the pubes. These large incisions heal quickly, and are no more prone to hernia than the short incisions. ”

“ She became cachectic—that is to say, her complexion assumed the ashy hue of a person dying of cancer; and her abdomen swelled as though she were again pregnant. Sir Spencer Wells in 1877 hazarded the guess that she probably suffered from “ovarian dropsy,” an old-fashioned term for what we should now call [89] “parovarian cyst,” a tumour that takes its origin from a little body adjacent to the ovary, and, being distended with fluid, causes enormous swelling of the abdomen. It is the one abdominal tumour which, if tapped, may possibly not return, and the patient may be cured with no further ado. ”

“ Primary cancer of the Fallopian tube is almost invariably unilateral and its association with fibroids of the uterus is unusual. It is necessary for the surgeon to remember that a cancerous Fallopian tube may lead to complications with an ovarian cyst. Our knowledge of primary cancer of the Fallopian tube has grown up within the last twenty years, and some of the recorded cases puzzled the reporters because the disease was associated with a cyst, sometimes of a large size. ”

“ The patient was a woman of twenty-eight whose abdomen at the umbilicus measured 69 inches in circumference and 47 inches from the sternum to the pubes. Before the operation the great tumor hung down as far as the knees, the abdominal wall chafing the thighs. Figure 263 shows the appearance of a large ovarian cyst weighing 149 pounds. The emaciation of the subject is particularly noticeable. Reifsnyder describes a native Chinese woman affected with an ovarian tumor seen at the Margaret Williamson Hospital at Shanghai. She was four feet eight inches in height, and twenty-five years of age. ”

“ DIFFERENTIATION.—Hæmatocele may be confounded with pelvic cellulitis or abscess, retroversion, extra-uterine pregnancy, fibroid tumor, and dislocated ovarian cyst.
The tumor of cellulitis develops slowly, with great pain; is hard at first, and then softens; is tender from the first; does not elevate the uterus or press it forward; and is not often accompanied by metrorrhagia.
Retroversion will readily be detected by the uterine sound, conjoined manipulation, and the absence of anæmic symptoms.
The development of extra-uterine pregnancy is slow and gives the signs of gestation. ”

“ A diagnosis was made of multilocular ovarian cyst or edematous myoma of the uterus, and on the morning of December 7, 1890, an operation was performed. An incision 14 inches in length was first made in the linea alba, below the umbilicus, and afterward extended up to the xiphoid cartilage. The hemorrhage from the abdominal wall was very free, and the enormously distended vessels required the application of a large number of pressure-forceps. Adhesions were found almost everywhere the most difficult to manage being those of the liver and diaphragm. ”

“ It occasionally happens that a woman may go through her pregnancy and labour with an unrecognized ovarian tumour in her abdomen; during the puerperal period it may cause symptoms which lead to its recognition, because in the course of the labour the cyst may burst, undergo axial rotation, or suppurate. When a puerperal woman possesses an ovarian tumour which gives rise to unfavourable signs, ovariotomy should be resorted to without delay. The operation in these circumstances is comparatively simple, and such adhesions as may be present are usually recent and easily overcome. ”

“ An incomplete ovariotomy is a very different condition to an enucleation. The cavity left after enucleation closes completely, but when the wall of an ovarian cyst or adenoma is left the tumour gradually grows again, or it may suppurate so profusely that the patient slowly dies exhausted. There are few things sadder in surgery than the slow, miserable ending of an individual who has been subjected to an incomplete ovariotomy. ”

“ McIntyre believes that his tumor, weighing 93 1/2 pounds, is the largest yet reported. Eastman reports the removal of a fibroid tumor of the uterus weighing 60 pounds. The patient recovered from the operation.
It is quite possible for a fibrocyst of the uterus to attain an enormous size, equaling the ovarian cysts. Stockard describes an instance of this nature in a negress of fifty, the mother of several children. About twelve years before a cyst in the right iliac region was tapped. ”

“ 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. ”

“ Papillomatous cysts also occur in the ovary. Parovarian and Gärtnerian cysts are found, and adenomata form 20% of all ovarian cysts. Occasionally the tunic of peritoneum surrounding the ovary becomes distended with serous fluid. This is termed ovarian hydrocele. Ovarian fibroids occur, and malignant disease (sarcoma and carcinoma) is fairly frequent, sarcoma being the most usual ovarian tumour occurring before puberty. Carcinoma of the ovary is rarely primary, but it is a common situation for secondary cancer to that of the breast, gall-bladder or gastro-intestinal tract. ”

“ They rarely attain a size greater than that of the adult fist. Exceptional cases have been reported in which the ovarian tumor was the size of the adult head. The tumor may be composed of one chief cyst-cavity, while the rest of the ovary may present a much less marked degree of cystic distention; or a large number of follicles may be uniformly distended each to the size of a cherry, forming an ovarian tumor as large as a child’s head. ”

“ 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. ”

“ Although he may begin the operation under the impression that he has to deal with an ovarian tumour, it may turn out to be a fibroid, a tumour of the pelvic wall, a misplaced spleen or kidney, a tubal pregnancy, a sequestered extra-uterine fœtus (lithopædion) , or a calcified hydatid cyst. Thus an expected ovariotomy may terminate as a Cæsarean section, or as a hysterectomy. In many cases the surgeon must rely on his own judgment and experience, but it may be useful to furnish some directions which may help him. ”

“ The diagnosis is not often difficult. When, as in chronic peritonitis and in tuberculous peritonitis, the fluid is confined in a sac or sacs, each particular pool will be yielding to pressure, but elastic, and will give the percussion wave, though it may extend but a short distance. To distinguish ovarian dropsy—ovarian cysts, as it is now called—from ascites may require a few words. Ovarian tumors of all kinds are found to be more prominent on one side when they rise from the pelvis than on the other. ”

“ N83.1 Corpus luteum cyst Hemorrhagic corpus luteum cyst N83.2 Other and unspecified ovarian cysts Excludes1: developmental ovarian cyst (Q50.1) neoplastic ovarian cyst (D27.-) polycystic ovarian syndrome (E28.2) Stein-Leventhal syndrome (E28.2) N83.20 Unspecified ovarian cysts N83.29 Other ovarian cysts Retention cyst of ovary Simple cyst of ovary N83.3 Acquired atrophy of ovary and fallopian tube N83.31 Acquired atrophy of ovary N83.32 Acquired atrophy of fallopian tube N83.33 Acquired atrophy of ovary and fallopian tube N83.4 Prolapse and hernia of ovary and fallopian tube N83. ”