On auscultation one hears vascular murmurs, Vat not so frequently as Wan believes. If they be present it is probable that the tumor belongs to the uterus, although such murmurs are rarely heard over ovarian cysts. In the differentiation between ovarian tumors and cystomyomata, it is first necessary to establish the relations existing between the uterus and the tumor in question.
If the tumor can only be moved together with the uterus, if it appears continuous with the uterine tissues, and if the sound when introduced into the uterine cavity, follows every impulse imparted to the tumor through the abdominal walls, the neoplasm is very probably a fibro-cyst. But all these phenomena are observed in cases of ovarian tumors which are closely connected with the uterus, as is not seldom the case. On the other hand, cases of uterine cysto-fibroma have been reported in which the tumor was attached to the uterus by means of a pedicle, was freely movable, and in short presented all the signs of an ovarian tumor.
Spiegelberg has announced that rectal palpation affords no further in formation in such cases. The only definitive information is obtained by puncture of the tumor. The trocar enters cysto-fibromata with difficulty, and very often only a few drops of sanguinolent fluid are evacuated through it. Although the same phenomena may occur with ovarian cysts, they are more characteristic of cystic myomata. If the fluid be clear, yellowish, slightly tinged with blood, and immediately coagulates when exposed to the air, we have to deal, not with an ovarian tumor, but as far as our present knowledge teaches,' with a cystic fibroma.
All these tumors have not, however, contents of this nature, and one accordingly often obtains, on puncturing the neoplasm, a bloody fluid filled with shreds of tissue, such as is occasionally found in ovarian tumors particularly malignant ones. The discovery of smooth muscular fibres, on microscopical examination, would establish the existence of a uterine fibro-cyst.
The question now arises whether puncture for the purpose of establish ing the diagnosis, be justifiable. Fehling and Leopold state that death occurred in ten out of eleven cases, as a result of the puncture. The
danger of the operation is dependent upon the fact that the walls of these tumors are unyielding, and readily allow the access of air. The trocar, moreover, easily produces hemorrhage in the vascular and degenerated tisues; experience must decide whether a tentative puncture by means of Dieulafoy's aspirator, be attended by similar dangers. I am inclined to believe, with McGuire,' that an exploratory abdominal incision, which will afford a view of the tumor, is the safest procedure, especially since extirpation of the tumor may be at once performed if the case be suitable for the operation.
Isolated cases, as that of Spencer Wells,' in which the autopsy revealed the fact that a tumor, considered ovarian during and after the operation, was in reality a uterine tumor, show that even exploratory abdominal in cision will not always establish the diagnosis. This fact is best illustrated by Virchow's case,' in which it was even difficult, at the autopsy, to recognize a preuterine ovarian sarcoma to be such, and to distinguish it prom a uterine tumor.
The symptomatic treatment of the tumors in question differs in no respect from that of uterine fibromyomata. We desire to earnestly dis parage the puncture of these fibro-cysts. Their extirpation by means of an abdominal incision, is rather indicated for their rapid' growth; and their tendency toward gangrene decidedly distinguishes them from ordinary sub-serous or other uterine myoinata.
The fact that fibro-cysts are far more dangerous than simple myomata is shown by the statistics of 0. Schriider and Heer, according to which the duration of the disease is relatively short. The longest period which elapsed before death was ten years, while many cases terminated fatally in a few months.
In speaking of the operations for the removal of uterine fibroids, it was stated that rapid growth constitutes an indication for early interference. Now cysto-fibromata are especially characterized by the rapidity of their development.
The cystic tumors are also more dangerous on account of their tendency to become gangrenous, and to lead to thrombosis.