cysts which, instead of growing free in the peritoneal cavity, develop
between the two layers of the peritoneum--intra-ligamentous ovarian
cysts, as Garrigues very aptly calls them in his paper on the
"Diagnosis of Ovarian Cysts."[12] In this excellent paper, from which I
have gleaned much, he says that sometimes the anatomical relations are
so lost that nothing short of a microscopic examination of the outer
epithelium can determine the character of the cyst. Thus, "a tumor
covered with columnar epithelium is ovarian, and cannot be anything
else; while the cyst of the broad ligament, being covered with
peritoneum, has flat peritoneal endothelium. In cases of
intra-ligamentous development of an ovarian cyst the lower portion is
covered by peritoneum, but the upper part has the columnar epithelium
characteristic of the ovary." There are, however, certain macroscopic
characteristics which will generally tell the nature of the cyst. For
instance: usually by a careful examination the corresponding ovary will
be found either stretched out and spread out in the wall of the sac,
or, what in my experience is more common, elongated and forming a part
of the stalk. These cysts are in the vast majority of cases monocysts,
while unilocular ovarian cysts are very rarely if ever met with. Their
walls are thin, of a conjunctival blue, and fretted with a delicate
network of blood-vessels. The oviduct is usually imbedded in the cyst,
and by transmitted light its fimbriæ can be traced out in the
cyst-walls in long fronds as delicate as those of dried and pressed
seaweed. Then, again, the peritoneal coat is readily stripped off. On
the other hand, in an ovarian tumor the oviduct is not ordinarily
incorporated in the cyst-wall; in fact, a meso-salpinx usually exists;
and, further, the peritoneal coat, being nailed down to the cyst-wall
proper by the cicatrices of ovulation, is not capable of being stripped
off.
[Footnote 12: _Am. Journ. of Obstetrics_, April, 1882, p. 394.]
{295} TREATMENT.--Since these cysts do not ordinarily affect the
general health or grow to a very large size, they should, as a rule, be
let alone. Whenever grounds for interference arise the cyst should be
aspirated, for sometimes after being wholly emptied it does not refill.
Should, however, the fluid return, the cyst must be extirpated in
precisely the same way as an ovarian tumor. When it is without a
pedicle it will have to be carefully enucleated from between the folds
of the broad ligament, which then cover it. If this cannot be done, all
of the cyst possible should be removed, the edges stitched to the
abdominal wound, and a drainage-tube put in. This is the advice
ordinarily given, but I have not yet met with a cyst of this variety
which could not be removed. Were such a one to occur in my practice I
should be tempted to remove all of the cyst possible, and to close up
the adherent portion in the cavity of the abdomen without resorting to
a drainage-tube. The fluid secreted by a parovarian cyst is so bland
that I believe no mischief would arise. The late Washington L. Atlee
was accustomed to make merely a large circular opening in the cyst,
without attempting to remove it.
Cysts of the Oviducts, or Fallopian Dropsy.
These tumors may contain either fluid or pus. In the former case the
cyst is called hydro-salpinx; in the latter, pyo-salpinx. They are
caused by salpingitis, or inflammation of the oviduct, which exists
rarely per se, unless of gonorrhoeal origin, but is one of the sequels
of pelvic peritonitis. The distension of the tube is due to the
occlusion of each of its ends. Thus by pelvic inflammation the fimbriæ
become glued to the ovary, sealing up the ovarian end, while an
endometritis closes the uterine opening. In addition to the dropsy of
the tube, I have repeatedly met with small cysts, or bladder-like
bodies outside of the tube proper, very analogous to those found on the
umbilical cord.
This affection is by no means an uncommon one, every age being liable
to it, and it is often the unrecognized cause of ill-health. Since Tait
first called the attention of the profession to the frequency of the
disease and the means for its cure, many cases have been reported in
which obscure pelvic symptoms were cured by the removal of the ovaries
and of the oviducts--the uterine appendages, as they are called.
DIAGNOSIS.--This is difficult, because the symptoms are those of pelvic
peritonitis or of pelvic cellulitis, the disease of the oviduct being
usually associated with that of the broad ligament. In some cases the
womb will be found movable, with a sausage-like tumor behind it; the
diagnosis is then easy. Usually, the symptoms are negative, and the
diagnosis is based upon constant groin-pains and recurring attacks of
pelvic inflammation.
TREATMENT.--Like hydrocele of Nuck's canal, hydro-salpinx occasionally
heals spontaneously, but more frequently it will need aspiration,
together with injections of iodine or of carbolic acid. When pus is
present, absorption probably never takes place, and an operation will
be needed. If the symptoms are grave enough to warrant an exploratory
incision, and dropsy of the tubes be discovered, both the tube and its
ovary should be extirpated, for in the great majority of cases the
{296} corresponding ovary will have undergone follicular or
interstitial degeneration. Unless there are very good reasons for
adopting a different course, both ovaries and tubes should be removed,
because the sound ovary, together with its tube, is liable to become
diseased. The incision should always be abdominal, and not larger than
to admit two fingers. The broad ligament is transfixed between the tube
and the ovarian ligament by a double ligature and tied on either side.
The operation is, in fact, analogous to that of öophorectomy. When the
tubes contain pus, they are liable to become adherent to the sigmoid
flexure, to the rectum, or to the small intestines, making their
removal very difficult--sometimes, indeed, impossible. The separation
of such adhesions requires the greatest care and delicacy.
Cysts of the Terminal Vesicle of the Oviduct.
A little bladder-like body, not larger than a pea, is often found
hanging by a thread-like stalk from one of the fimbriæ of the oviduct.
It is a relic of foetal life, being probably the remains of the
Wolffian body, and sometimes goes by the name of the hydatid or vesicle
of Morgagni. The walls are very thin and covered by peritoneum. What
rôle these vesicles play in the economy is uncertain, but they have
been found to undergo cystic degeneration. They rarely attain to a size
larger than that of an orange, and then either remain stationary or
else burst. I have met with several examples of cysts which, after
reaching the above size, did not grow any larger. I have also met with
one case in which, after attaining the bulk of a small apple, the cyst
burst, and immediately refilled, to burst again and again at intervals
of from four to six weeks.[13] The collapse of the sac was attended
each time by colicky pains, but of no great severity.
[Footnote 13: "Bursting Cysts of the Abdominal Cavity," by Wm. Goodell,
_Trans. Amer. Gynæcol. Soc._, 1881, p. 228.]
Other small cysts I have met with which either burst under the pressure
of the examining finger or were designedly burst by bimanual pressure.
These, I am disposed to think, were cysts of the terminal vesicle of
the oviduct. These cysts are of but little surgical importance, as they
rarely need operative interference. If such should arise, they are to
be treated by aspiration, and if this fails by extirpation.
Solid Tumors of the Round Ligament.
These are occasionally met with, and usually on the right side. They
belong to the connective-tissue group, being either myoma, fibroma, or
sarcoma. They form at any point of the round ligament, and may
therefore be either intra-peritoneal, intra-canalicular--that is, in
the inguinal canal--or extra-peritoneal. The symptoms are those arising
from pressure, and are not at all diagnostic. The only treatment of
these tumors is removal, but, as their growth is very slow, they are
not to be touched unless the symptoms become exacting.[14]
[Footnote 14: _Medical Times and Gazette_, Dec. 1, 1883.]
{297} OVARIAN TUMORS.
The morbid growths of the ovary are conveniently divided into the solid
and the cystic.
The solid ones are either benign, under the form of fibroma, or
malignant, being then either carcinoma or sarcoma.
Fibroid Tumor of the Ovary.
Fibroid degeneration of the ovary is so rare a form of disease as to be
denied by excellent authorities, who contend that all the cases
reported under that term were pedunculated uterine fibroids, which had
so grown around and so involved the corresponding ovary as to be
mistaken for an ovarian fibroid. Yet while such mistakes have
undoubtedly been made, there can be no question that ovarian fibroid
does occasionally present itself as a rare form of disease.[15] Out of
155 cases of ovariotomy thus far performed by myself, I have met with 4
undoubted cases of ovarian fibroid. The tumors weighed respectively 2,
3, 4, and 15 pounds, and in each, with the exception of the first,
abdominal dropsy was the prominent symptom. All but one of these cases
promptly recovered.
[Footnote 15: _Brit. Med. Journ._, March 18, 1882, p. 384.]
According to Francis Delafield,[16] "The structure of a fibroid of the
ovary resembles that of the ordinary fibroid tumors of the uterus. That
is, they are composed of connective tissue and smooth muscular fibre.
The tumor, therefore, is a myo-fibroma. There has been some question
whether ovarian tumors ever contain smooth muscle, but the best
authorities now admit that it does sometimes exist in such tumors."
[Footnote 16: _Boston Med. and Surg. Journ._, Nov. 17, 1881, p. 461.]
Occasionally these tumors arise not from a general hypertrophy of the
whole ovary, but from a nodule or a tumor growing in and from the
stroma of the ovary. Solid ovarian fibroids are of slow growth and
rarely attain a large size. When, however, they are of the geode
variety, with numerous cystic cavities, they grow rapidly and may reach
enormous proportions.
DIAGNOSIS.--The only other abdominal tumor for which it is very likely
to be mistaken is a pedunculated fibroid tumor on the peritoneal
surface of the womb, and with our present knowledge it seems impossible
to tell them apart.
When they float about in ascitic fluid they often give the sign of
ballottement in a very perfect manner. From carcinoma of the ovary they
can generally be told by their smooth surface.
PROGNOSIS.--Fibroid tumors of the ovary grow so slowly that, like
pedunculated fibroid tumors of the womb, they ordinarily do not attain
a very bulky size. When the climacteric is reached they tend, like the
latter, to stop growing and to undergo a calcareous degeneration. More
often, however, they cause by their presence a dropsical effusion of
the abdominal cavity, which has to be repeatedly drawn off; and it is
for this reason that they usually have to be extirpated. They are
removed precisely in the same way as an ovarian cyst, and the prognosis
is equally {298} good, but they are liable to have short and broad
pedicles which need to be tied very carefully in sections.
Malignant Diseases of the Ovary.
These affections are either primary or secondary. When secondary, they
follow analogous diseases of the womb or of the pelvic structures. When
primary, they appear under different forms, as in other portions of the
body, being either encephaloid, scirrhous, melanotic, or papillary.
Colloid cancer of the ovary may be practically excluded, because it is
of extreme rareness. The term colloid when applied to ovarian cysts
refers more to the gluey consistency of the contained fluid than to the
question of malignancy. In my experience the most common form is that
of papilloma, which, however, like villous growths elsewhere, is not
always malignant. I have removed papillary cysts and villous growths of
the ovary, yet the subsequent history of the cases proved that the
tumors were benign. The only macroscopic distinction between the benign
and the malignant form which I have hitherto attempted to make is, that
in the malignant form papillary growths will be found in patches upon
adjacent structures, or else the womb and the broad ligaments are also
involved in one cauliflower-like tumor. But Tait observes that he has
had two cases of ovariotomy in which he left large masses of papilloma,
fixing the womb, yet in each case these masses wholly disappeared, and
the patients are both in perfect health.[17]
[Footnote 17: _Diseases of the Ovaries_, 4th Am. ed., p. 147.]
There is, however, no question that malignancy lurks in many ovarian
cystomata which present to the naked eye an innocent appearance.
The patient recovers promptly from the operation for their removal, but
dies a few months later from cancer of the peritoneum or of other
organs. Every ovariotomist has met with such examples. In one of my own
cases, in which not the slightest sign of malignancy was apparent, the
patient wholly recovered from the operation. Shortly after her
convalescence an effusion took place in the right pleural cavity. The
chest was tapped three times before her death, which was due to cancer
of the liver and of the broad ligament at the site of the ablated
ovary. In my first case of ovariotomy, one in which the clamp was used,
menstruation took place regularly for several months from the cicatrix,
which within a year became affected with cancer.
Both ovaries are usually involved in cysto-carcinoma, and this fact
should be borne in mind in making a diagnosis. From the marvellous
changes often produced progressively in the epithelial linings of
ovarian cysts, by which they are transformed into tufts of villous
cancer, Tait inclines to the opinion that their growth is associated
with a tendency toward malignancy. He believes that tapping hastens on
this degeneration, and that after an accidental rupture of such a cyst
the peritoneum will be found studded with patches of papillary cancer.
Hence he argues that ovarian cysts should never be tapped, and that
they should be removed in the earlier stages of their existence, before
these malignant transformations have taken place.[18]
[Footnote 18: _Op. cit._, p. 148.]
DIAGNOSIS.--Since, as has been shown, this cannot always be made {299}
out, even by the eye, after the removal of the cysts, it follows that
in a large proportion of cases the malignant character of the
degeneration cannot be recognized. There are, however, certain symptoms
pointing to malignancy which will often throw much light. These, in the
order of their frequency, are--
(_a_) The presence of ascitic fluid or of oedema of the lower
extremities when the tumor is too small to produce such
pressure symptoms.
(_b_) General cachexia, rapid emaciation, and grave constitutional
disturbance out of all proportion to the size of the tumor.
(_c_) The hardness and solidity of the tumor, together with its
nodulous and irregular surface.
(_d_) The concurrent development of two ovarian growths.
(_e_) The retraction and burying of the cervix in the vaginal vault.
(_f_) Pain in stabs, starting from the groin and running down the
inside of the thigh. But pain is not a trustworthy symptom,
as it is often absent, especially in cysto-carcinoma, and may
be caused by benign growths as well.
TREATMENT.--Whenever no doubt exists as to the malignancy of an ovarian
growth, an operation looking to its removal should not be urged by the
physician. On the other hand, since a positive diagnosis on this point
is rarely attained, and since cancer of the ovary tends for a long time
to remain localized, whenever a suspicion of malignancy exists
ovariotomy should be performed early, before adhesions have been
contracted with neighboring structures. In such a case I should incline
to burn off the pedicle in preference to using the ligature.
In those cases in which, on account of adhesions, no operation is
justifiable, palliative treatment can alone be resorted to. This
comprises the removal of the ascitic fluid or the contents of the cyst
by the aspirator whenever the pressure becomes uncomfortable. Symptoms
should be treated, and, that of pain being the most urgent, opium will
be needed up to the last in increasing doses.
Dermoid Cyst, or Piliferous Cyst of the Ovary.
A dermoid cyst is a congenital tumor having a wall composed of elements
like true skin, with its appendages of hairs, sebaceous glands, etc.,
and contains teeth, hair, bone, cartilage, muscle, and a cheesy
material very like vernix caseosa. These cysts are solitary, two never
being found in the same person, and, further, they are always
unilocular. They are either external or internal--that is, they affect
either the surface of the body or else the cavities of the body, as
"under the tongue, in the pharynx, oesophagus, cranial cavity,
peritoneal cavity, lung, ovary, testis, bladder, and kidney."[19] No
tumors are more curious, and none are more puzzling to explain. The
theories accounting for their origin are very remarkable, and are as
follows: Excess of formative nisus. Parthenogenesis, or virgin birth;
that is to say, imperfect imitation of transmitted fertility--a
property peculiar to many insects, by which, without any renewal of
fertilization, successive generations of procreating individuals start
from a single ovum. Inclusion of abnormal structures, {300} where there
is a dipping in of the epiblast to meet the hypoblast during foetal
life, and the pinching off of the same. Foetus in foetu--viz. the
inclusion of an imperfectly developed ovum within another which matures
perfectly. Hypererchesis; which means that "the ovum has in it the
origin-buds of certain tissues, which under exceptional hypererchetic
action may go on to the rudimental formation of these tissues without a
fusion with the male germ."[20] According to Elsner, who has written
last on this subject, and to whom I am indebted for much information,
"dermoids occur externally and internally in places where the epiblast
dips down to meet the hypoblast, and where by processes of grooved
involution new bodies are formed, such being, first in order, the
testicle and ovary, and that they are therefore all (without exception)
embryonal in their first structure."
[Footnote 19: Elsner, _Dublin Journal Medical Sciences_, May, 1882, p.
380.]
[Footnote 20: _Diseases of Ovaries_, by L. Tait, 4th ed., p. 177.]
SYMPTOMS.--These congenital tumors begin early in life, and usually
remain dormant until puberty. Then the periodic congestions of
menstruation usually stimulate them into growth. Sometimes they need
the increased vascularization of pregnancy. They are more liable than
ovarian cysts to inflammation and suppuration, but they grow much more
slowly, and very rarely reach the large size of the latter. They are
also very liable to contract adhesions to every structure they touch,
making their extirpation very difficult and sometimes impossible. Often
they create pain out of all proportion to their size. Occasionally,
they break and empty their contents through fistulous communications
with the intestines, bladder, or the abdominal wall. But collapse of
the usually thick walls of the cyst does not take place, and a cure
results far less frequently than in pelvic abscesses, which empty
themselves through analogous channels. The cyst ordinarily does not
lessen in size; suppuration goes on with hectic fever and exhaustion,
which finally carry off the patient.
DIAGNOSIS.--Quiescent or slow-growing pelvic tumors, semi-solid to the
feel, and first discovered at the age of puberty, are usually dermoid
cysts. Their small size is also an aid to diagnosis, for they very
rarely reach the bulk of the adult head. On several occasions I have
found them in Douglas's pouch, fig-shaped and flattened in their
antero-posterior diameter. From its attachments to neighboring
structures a dermoid cyst is very liable to be mistaken for the cyst of
an extra-uterine foetation. But the exclusion of the history of
pregnancy and the slow growth of a dermoid cyst, unless suppuration has
taken place, ought to distinguish the one from the other.
TREATMENT.--While quiescent the cyst should not be touched, as it is
very vulnerable and liable to resent the slightest injury, even from
the slender trocar of the aspirator. If suppuration takes place and the
tumor points to the surface, it should be treated, like any other
abscess, by a free incision, by the evacuation of its contents, by the
introduction of a drainage-tube, and by the injection of antiseptic
solutions. Small cysts lying in Douglas's pouch can sometimes be cured
by aspiration; at least I have twice succeeded in obliterating them in
this way. The operation was, however, followed by suppuration of the
cyst, the abscess bursting into the vagina. If after an exploratory
incision an abdominal cyst turns out to be dermoid, it should be
extirpated. But if extensive adhesions {301} preclude such an
operation, the cyst should be opened, evacuated, and thoroughly
cleansed. The edges of the opening should then be stitched to those of
the abdominal wound and a drainage-tube put in. The after-treatment of
such a case will be analogous to that of an ovarian cyst under like
conditions, to which the reader is referred.
Cystic Tumors of the Ovary.
These represent by far the most frequent variety of ovarian tumors, and
as such demand our best attention. They consist, in probably the
majority of cases, in a dropsical enlargement of one ovisac or of
more--viz. in a follicular dropsy. Indeed, as Cazeaux has aptly said,
the ovisacs, or Graäfian follicles, are ovarian cysts in miniature.
These cysts are divided into three classes, which depend wholly upon
the number of ovisacs involved. Thus, a single, or barren, cyst,
containing merely fluid, is called a monocyst or unilocular cyst. Such
a cyst would be due to the dropsical enlargement of but one ovisac. It
is extremely rare--so much so that its existence is denied. The
probability is that a one-chambered sac does not begin as such, but it
becomes so through the breaking of the walls of other contained cysts.
A multiple cyst is caused by the simultaneous growth of two or more
ovisacs, one of which usually takes the lead in growth and keeps the
others dwarfed. This form of cyst is by far the most common. It grows
with great rapidity, and may reach a weight of over one hundred pounds.
I have successfully removed one weighing one hundred and twelve pounds.
A proliferous cyst is a mother-cyst packed with innumerable child-cysts
of varying size. These endogenous cysts multiply by exogenous and
endogenous growth. The proliferous cyst rarely attains to the size of
the multiple cyst, but surgically it is a solid tumor, because it
cannot be emptied by tapping, and therefore often needs a long incision
for its removal. It also usually possesses a very thin wall, which is
liable to be torn during the needful manipulation for its removal.
Racemose cysts are occasionally met with. They consist of a number of
isolated cysts of varying size attached to one common stalk like a
bunch of grapes. I have met with two such examples. Tait thinks that
they are "produced by the retention of the ova in the Graäfian
follicles, and the distension of their cavities by a continuous
secretion of the liquor folliculi."
The pedicle or stalk by which an ovarian cyst is attached to the womb
consists of the corresponding broad ligament, oviduct, ovarian
ligament, and vessels. The pedicle is sometimes long and slender, at
other times short and broad. There is one form of ovarian cyst which
has no proper pedicle. It grows between the two layers of the broad
ligament, and tends to develop downward into Douglas's pouch. 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.