UTERINE MYOMATA. — Slow growth, resistance of the tumor, presence of multiple growths, irregular contour, and relation to the uterus afford confirmation in the diagnosis. The difficulty may be as great in oedematous fibroids and in fibrocystic tumors. Double ovarian cysts, particularly where the pediele is short or absent, may so drag up the fundus uteri as to make it appear that they are a part of the organ itself. The relation of the uterus to the tumor is best determined by drawing down upon the cervix with a vulsellum, which is held by an assistant, while a second as sistant draws up the tumor through the abdominal walls and simultaneously the operator with one or two fingers in the rectum, the hand over the abdomen, seeks the pedicle and determines its re lation to the uterus.
It is often impossible to distinguish fi broma of ovary from a pedunculated sub serous uterine fibroid. Hegar's method of diagnosis is trustworthy; the finger is passed into the rectum, and pressed against the tumor, at the same time the uterus is drawn downward by a volsella. If the tumor be ovarian, it will not move; if uterine, there will be great resistance to drawing down the cervix, which will clearly be continuous with the morbid growth. True fibroma of the ovary often sets up ascites, yet is rarely adherent to adjacent structures. It is never invested by a distinct cap sule, like a uterine myoma. It under goes different kinds of degeneration, even malignant, contrary to the opinion of many observers. Barremano (Ann. de l'Instit. de St. Anne, Bruxelles, vol. ii, No. 93).
Third, the relation of the tumor to the surrounding parts, the character of the pedicle, and the presence of adhe sions. The mobility of the tumor is de pendent upon the length of its pedicle and the absence of adhesions. The tu mor which can be pushed about without dragging upon the uterus and can be displaced from side to side, the abdom inal wall sliding over it, is recognized as free from adhesions and having a long pedicle. Rapid enlargement, tenderness of the abdomen, sensation of crepitus as the abdominal wall is moved over the tumor, indicate recent and extensive ad hesions from peritonitis. Limited adhe sions of the omentum, intestine, and abdominal wall cannot be excluded.
Torsion of the pcdicle is recognized by the onset of sudden and severe peritoneal symptoms, severe pain in the belly, mete orism, vomiting, and accelerated temper ature. Rapid growth of the tumor and tenderness of its surface indicate that torsion has been followed by intraevstic hrnmorrhagc or increased exudation.
Sudden collapse followed by symptoms of internal humorrhage and peritoneal irritation indicate the occurrence of hwm orrhage. Acute torsion is difficult to dif ferentiate from rupture of an ovarian cyst, and peritonitis from perforation of the stomach or intestines, renal or gall stone colic, ileus, and rupture of ectopic gestation. We can only arrive at a con clusion from careful investigation of the history.
Inflammation of the tumor is charac terized by sensitiveness, radiating pain, sudden enlargement, or the suppuration lead to the formation of gas and the development of tympanitic resonance. Rupture of a cyst is recognized by sud den oppression, suffocation, nausea, some times vomiting, diarrhoea, acceleration of the pulse, moderate elevation of tempera ture, presence of free fluid in the peri toneal cavity, and indication of decrease in the size of the tumor, with strong diuresis. Tumor limits are indistinct and there is no alteration of resonance with the change of position.
Diagnosis as to Varieties of Ovarian Tumor. — The glandular proliferating cyst is the most frequent, and attains the largest size. They are mostly multi locular, and consequently present a less marked wave of fluctuation. Fluctuation is an indication of its cystic character and is very distinct in the unilocular and large chambered cysts. Instead of fluct uation we not infrequently find elastic stretching which can be produced by (edematous, solid growths, and enlarged cysts whose contents are made up of col loid or very thick, viscid material. In fluctuating or tough, elastic tumors which are nodular we find a cystadcnoma. A large fluctuating tumor is not necessarily a unilocular cyst; generally a small cyst which makes no symptoms is not a cyst adenoma, but a dermoid or parovarian, or, more probable still, a simple retention cyst of the ovary.