Diagnosis of pelvic Tumor?, 
BY 
E. W. CUSHING, M. D., 
OF BOSTON. DIAGNOSIS OF PELVIC TUMORS. 
By E. W. CUSHING, M. D. 
OF BOSTON. 
READ BEFORE THE 
NEW HAMPSHIRE MEDICAL SOCIETY, 
AT THE NINETY-EIGHTH ANNIVERSARY, HELD AT 
CONCORD, JUNE 17 AND 18, 1889. 
Ccmxcrrtr, |J. Jp.: 
Republican Press Association, 22 North Main Street. 
1889. DIAGNOSIS OF PELVIC TUMORS. 
I have been invited by your president to make a few remarks 
with reference to the diagnosis of pelvic tumors, and the indi- 
cations for operation. This is a subject, I am sure, which will 
interest all of you, and of which there is not much written in 
the text-books. There is a good deal said about abdominal 
tumors, and when they become large they are comparatively 
easy to diagnosticate, but nearly all of these have been at one 
time pelvic. The next step in progress is in finding them out 
when they are little, before they are abdominal tumors, when 
they are not so easily distinguished. 
I think you will all recognize the very great addition to 
safety in operating on such things when they are small; yet it 
is not generally appreciated that something like sixteen or seven- 
teen per cent, of the ovarian growths become malignant when 
they get large, so that in operating on one hundred large ones 
something not very far from sixteen are found to be malignant, 
with great increase in mortality, and a strong disposition to 
return. Again : When large they pass through all forms of 
danger incidental to obstruction and adhesions, and it is often 
very difficult to dissect them out, whereas the small tumor 
without adhesions is the simplest thing in the world to remove. 
In diagnosticating these cases, when is one to use ether? My 
experience is, that in examining patients there is an involuntary 
pressing down upon the organs of the pelvis, which comes 
from the abdominal tension, and especially is that the case 
when the parts under examination are at all sensitive. There- 
fore, in cases requiring operation, it is not fair to yourselves or 
to others to expect a satisfactory diagnosis in a case which is 4 
at all doubtful without the benefit of ether. With that aid 
many cases are wonderfully cleared up. 
Now, in regard to the varieties of the tumors within the 
pelvis : leaving out fibroid uterine tumors, we have to refer 
them to the uterine appendages and to the broad ligament and 
its contents. 
We have, in the first place, the stroma of the ovary, which 
is apt to become cystic and have a multilocular development. 
At first such a tumor is small, but it constantly enlarges by 
little new points of development, daughter-cysts forming in the 
walls of the first cyst, until it makes a composite tumor. One 
cyst is usually much larger than the others. I have brought 
with me some specimens, and have here a little tumor of that 
kind. In the first stages, such a tumor will be found to be 
perfectly movable, not adherent or fixed. The tumor here 
shown was discovered accidentally, the woman being under 
examination for some other trouble. The removal of a tumor 
like that, at that stage, with only a thin pedicle, is absolutely 
insignificant in comparison with the severity of the operation 
if that same tumor or growth is left until it is larger, until it 
becomes adherent, or has given rise to attacks of localized 
peritonitis, and, moreover, if not removed, it is liable to become 
malignant. You will see that a tumor of that kind is usually 
single, very movable, smooth, nearly round, hard, but not as 
hard as the fibroid. It is painless, and when small is found to 
be on one side or the other, in the region of the ovary. It can 
be pushed up and felt from above, or pushed down, or behind 
the uterus. 
Secondly. We have a tumor coming from the hilum of the 
ovary, or, it may be, coming from the vertical ducts of the 
parovarium. It is not simple ; it has sacs filled more or less 
full with fluid and papillary excrescences. I have such a one 
here, a little larger than the other shown you, but still it is a 
little tumor, growing between the folds of the broad ligament. 
It has no pedicle, and when it is small it is very easy to shell 
it out, but when it becomes large it is a very difficult matter. 
What do these papillae do? They finally may fill up the 
tumor, and if there is some weak spot in the walls, they are 
liable to come through, and the tumor is turned inside out. If 5 
the tumor bursts, or if you tap it, these masses of rapidly grow- 
ing cylindrical epithelium will infect the peritonaeum in thou- 
sands and thousands of places, so that it may be all covered 
with little papillae. This tumor grows, as already stated, from 
the vertical ducts of the parovarium, from the hilum of the 
ovary, or from the remains of the duct of Gartner, and in the 
latter case it is found in the walls of the uterus. Papillomatous 
cysts are apt to be double, and, growing between the folds of 
the broad ligament, they contract firm unions and adhesions, 
becoming, if neglected, very dangerous and formidable. 
The third kind of tumor of the broad ligament is a very sim- 
ple one when little. It is a simple cyst containing serous fluid 
and lymph, growing between the folds of the broad ligament. 
These cysts are liable to develop, growing larger and larger. 
When little, as with the other tumors spoken of, they are easily 
removed, and if discovered in time and removed, or even if 
punctured, they seldom return. They are found on one side 
only. 
The next that we have is the dermoid cyst. Here is such a 
one, that was found growing in the pelvis in a young woman. 
It was developed from the ovary. Another in the other ovary 
was larger, containing hair and teeth. One of these is very 
likely to make a great deal of trouble eventually. It is likely 
to be painful as it grows, and if it is broken or tapped the con- 
tents will spread about and set up inflammation. These cysts 
are filled with fat, hair, and teeth, and I have no doubt that 
you will find this one so. I will open it for you, as I do not 
know of an occasion where it can be put to better service. 
You will see the hair, and it is very likely that, if it were exam- 
ined closely, teeth could be found. Dermoid cysts are not 
limited to the ovary, the)7 are occasionally found in the strangest 
places. They are considered to be congenital, and may be 
carried through life without trouble, but rarely. They are apt 
to be double. 
Totally different from the ovarian tumors are the myomata 
of the uterus, commonly called fibroids. In most cases there 
is not any great difficulty in making a diagnosis of these, at 
least under anaesthesia and with the aid of bimanual palpation, 
and the measurement of the depth of the uterine cavity with the 6 
sound, if necessary. The long duration, the history of hem- 
orrhages, the comparative freedom from acute pain in uncom- 
plicated cases, the slow growth, the irregular shape, the hard- 
ness, the distortion and elongation of the uterine cavity, all 
facilitate the diagnosis. Nevertheless there are cases where 
these signs fail, or are conjoined with others which are confus- 
ing. Precisely the cases which give most trouble and most 
require an accurate diagnosis are those where it may be 
impossible to say with certainty before operation whether a 
fibroid is present or not, and whether, if present, it is uncompli- 
cated. For those small fibroids, which cause most suffering, and 
on account of which the question of operation is most frequently 
raised, are those in which there is also present an inflammation 
of the Fallopian tubes, with repeated attacks of violent pain and 
of pelvic peritonitis, so that the fibroid is imbedded in masses 
of exuded lymph, and is fixed, tender, and perhaps not very 
large. 
On the other hand, any of the forms of tumor above men- 
tioned may be present, together with a uterine fibroid, and 
each may mask the presence of the other more or less. Where 
there is no fibroid, the masses accompanying the diseases of 
the tubes, which will be next considered, may be so large, 
so hard, of such long duration, and so complicated with 
menstrual hemorrhages, that a diagnosis is only possible on 
opening the abdomen. At least operators of gi'eat skill and 
experience are frequently unwilling to make a positive diag- 
nosis before operation, and the greater the experience, the 
greater is apt to be the unwillingness. 
These other morbid enlargements of this region are not 
tumors in the common acceptation of the word, nor yet are 
they growths, but masses, and they have to be distinguished 
from the tumors. They are the diseases of the Fallopian tubes, 
or abscesses of the tubes and their vicinity, forming what is 
often called cellulitis. These may closely resemble in size the 
fibroid or the ovarian tumors, but in almost all of these cases 
there will be inflammation from the first. With most of the 
other kinds of tumors described above the inflammation comes 
later, from the irritation of the peritonaeum, torsion of the 
pedicle, rupture of the cyst, or obstruction of the intestine. 7 
These tubal affections are caused often by gonorrhoea; 
often by puerperal disease; sometimes, perhaps, by simple 
inflammation connected with menstrual troubles. The history 
is generally obscure, and one has to come back to the fact that 
there has been at one time a very severe inflammation, with 
more or less complete recovery. 
Now, here is a case where a woman (and she was a faith- 
curist, by the way) concluded to undergo an examination. 
There was a distinct history of inflammation, history of pain, 
and difficulty of menstruation, etc. This mass could easily be 
found, and when it was removed, it was three times as large 
as it is now after preservation in alcohol. In examination 
under ether such a mass is not movable, as the small tumors 
are : it is fixed there. In fact, it is generally supposed to be in 
the broad ligament, but it is not. It is in and around the tube. 
That woman was on her feet going about, and had been suffer- 
ing for a long time. This big tube was full of pus. This cyst, 
formed by the other tube and ovary, with adhesions to neigh- 
boring parts, was full of serum. It broke in removing it. 
Now you see that these are about the size of the smaller 
forms of tumors. They, however, are not movable, and there 
is great sensitiveness and inflammation which do not accom- 
pany the tumors. The tubes are full of pus, or cheesy masses, 
and the uterus itself may be turned back, and it will generally 
be found to be pressed out of place by the pus-tubes. 
Here is another of these doubtful tumors. In this case, the 
woman lay in bed three years, with violent menstrual hemor- 
rhages and much pain. It was difficult to tell what the trouble 
was. The bunch was hard, and it was not evident whether it 
was in the tubes or was a fibroid. It proved to be the former ; 
the tubes were removed, and the patient recovered very nicely. 
The second thing that we have to anticipate in the tube is 
tuberculosis. Here is a case which shows it very perfectly. 
This was removed in my presence, and was given to me by my 
friend Dr. Reamy, of Cincinnati. You can see the little miliary 
tubercles on the walls of the tubes, as well as the cheesy matter 
in their cavities. One ovary by chance contains or is turned 
into a dermoid cyst as large as an egg. That represents the 
early stages. 8 
Here is another case where the tuberculous condition had 
gone on further. The woman was run down ; she had lost forty 
pounds within a few months. It was thought that she had a 
fibroid tumor, but upon operation there was found this diseased 
condition of the tubes, reaching clear down to the wall of the 
uterus. 
In regard to operating on women run down in health, who 
appear to have some pelvic difficulty, and especially such a 
severe case as this last, I would say, that although it would 
appear at first as though the patient could not recover, even 
though undergoing an operation, it seems as though the cases 
published by Hegar and others, showing recovery after opera- 
tions for tuberculosis of the tubes, furnish hope that a favora- 
ble result may ensue, and a justification for such operations. 
The only other diseased conditions which I think of that are 
liable to occur in this region are the malignant affections and 
extra-uterine pregnancy and pelvic haematocele. Cancer of 
the uterus comes in for discrimination, but only that form 
which, originating in the fundus, spreads to the neighboring 
parts and causes an infiltration of the broad ligaments, with 
fixation of the uterus. In these cases the age, the pain, the 
rapid loss of strength, and usually the sanious and malodorous 
discharge, make a diagnosis not difficult. Earlier in the history 
of the case, when the disease is limited to the mucous mem- 
brane, with enlargement of the uterine body and repeated hem- 
orrhages, the uterus being movable and the pelvis free from other 
disease, there may be a doubt whether the affection in question 
is a malignant adenoma or a uterine fibroid. The fact that the 
former is in most cases a disease of women who have passed 
the menopause, is generally a strong ground of diagnosis ; but 
as the symptoms require curetting, the slightest inspection of 
the masses removed will distinguish between the presence of a 
fibroid and that of an adenoma, while the microscope will 
show whether the latter has already undergone cancerous de- 
generation. These uterine adenomata, before the uterus is 
fixed by malignant degeneration and infiltration of the broad 
ligaments, form the most suitable and useful field for vaginal 
removal of the whole uterus. Malignant disease may also 
spring from the ovaries, tubes, or intestine, giving rise to great 9 
difficulties of diagnosis. Cancerous ovaries usually are associ- 
ated with a great accumulation of fluid in the peritonaeum. 
The cases must be very rare where extra-uterine pregnancy 
could be confounded with pelvic tumor. In the first place, an 
opportunity is seldom offered of examining a case of ectopic 
gestation before the rupture of the tube in which it lies has 
either precipitated symptoms of abdominal collapse and acute 
anaemia, which are sufficiently characteristic and are soon fatal, 
or by rupturing into the cavity of the broad ligament has caused 
a pelvic haematocele. If such an opportunity does occur, the 
physical symptoms are not sufficient to warrant a diagnosis, 
and the distinction from tubal distension of other varieties must 
be made by the history of the case and the other signs of preg- 
nancy. Such a diagnosis is not usually possible, in the opinion 
of Tait, as he says “we may guess but we cannot affirm.” 
Although undoubtedly some such cases have been recognized, 
yet these are the rarities. On the other hand, I know of a case 
where a competent operator removed a diseased and distended 
tube, and was much astonished afterwards to find that it con- 
tained a little foetus. In another celebrated case, which has 
been quoted as an example of the possibility of making a diag- 
nosis before rupture, I am credibly informed that at a consulta- 
tion held on the afternoon previous to operation it was held to 
be impossible to decide what the tumor was. 
If the tube ruptures in such a manner as to cause a pelvic 
haematocele or haematoma, the symptoms ai*e so sudden and 
violent that there is no great probability of confounding the 
condition with anything else. The tumor which is produced 
is low down, and although at first on one side, it soon passes 
around behind the uterus which it encircles like a collar, press- 
ing it forward, and also pressing on the i*ectum. The symp- 
toms of haematocele are well known, and are described at 
length in the text-books. 
I would like to say a few words in regard to operation on 
pelvic growths. I think everybody is agreed that an operation 
is warranted as soon as a tumor is diagnosticated. The dan- 
ger of letting such a growth remain until it becomes large is 
so great, and the operation on a small one is so insignificant, 
that no one should hesitate for a moment what course to pursue. 10 
The indications to warrant operations on pelvic inflammatory 
diseases are much more difficult to define. Where there is pus, 
where there is fever, and when the woman is confined to her 
bed and is incapacitated, nobody need hesitate to advise an 
operation. Where, however, the woman is only somewhat in- 
capacitated, not obliged to keep her bed, an operation depends 
somewhat upon her circumstances and condition. In case of a 
woman who has a home, who can be supported, and can have 
her work done for her, not being obliged to labor, I think there 
is quite a conservative feeling among surgeons as to the neces- 
sity for operation. An operation on these chronic diseases of 
the tubes is much more difficult and dangerous than on a tumor. 
Therefore an operation on chronic catarrhal salpingitis is de- 
pendent very largely upon the necessity of the patient for labor. 
The woman who must work for her living, who loses one place 
after another, who has no home to go to, is perfectly willing 
to undergo the dangers of an operation rather than to live on in 
that way. A woman in that position, I think, has a right to 
have that wish respected and receive the operation. As I have 
said before, where the woman is able to be about, and is not 
obliged to work, there is much less necessity for an operation ; 
but where the woman has to keep her bed, where the tubes are 
full of pus, and where there is constant inflammation, that pa- 
tient is not going to get better without an operation, and I be- 
lieve that it is a neglect of duty to advise against its perform- 
ance. 
168 Newbury Street