Volume 3

A system of medicine / edited by J. Russell Reynolds ; with numerous additions and illustrations, by Henry Hartshorne.

Date:
1880
    ful. Menstruation may be scanty, mod- erate in quantity, or profuse ; sometimes there is amenorrhcea. When the disease is of long duration, nervous symptoms set in. Curious sen- sations are felt in the side affected. These are not uecessarily limited to any one spot, but are experienced over the whole of that half of the body. The patients become hysterical and often confirmed invalids. On examination of the abdo- men one ovarian region is found fuller than normal—the fulness being due to flatus. Patients often say they have a swelling in that situation, and believe themselves to be the subjects of a tumor. The part is tender, especially on deep pressure. Bimanual examination, made with one hand on the abdomen and a finger of the other in the vagina or rectum, will in most cases discover the ovary enlarged and tender. The organ is often but not always prolapsed, and occupies a position behind and a little to one side of the uterus. Pressure on it causes severe pain, and in some cases nausea. There is no marked fever, though there are often slight febrile attacks. The digestive functions are impaired. The tongue is furred, and the appetite lost; the bowels obstinately con- fined. Sterility is often present, espe- cially in women who have not borne children, and who are the subjects of chronic ovaritis. Sterility is far less common in women who have accpiired ovaritis after labor. The disease very rarely proves fatal; it is, however, one of long duration. The chief danger lies in the liability to perito- nitis. Both acute and chronic ovaritis are diseases of the reproductive period of life. The chronic form which follows labor is far more tractable than that associated with primary dysmenorrhcea. I do not think I have seen a case of the latter kind cured while the uterus and ovaries con- tinued to perform their physiological functions. Rest is an important clement in treat- ment. Physical rest may be readily ob- tained, but plrysiological rest is not possi- ble during menstrual life. Bromide of potassium is said to be useful, but I can- not say I have seen any good results from its administration, except when given in large doses at bedtime for three or four nights in succession before a menstrual epoch. Better results are obtained by general treatment and counter-irritation over the painful ovary. The bowels should be kept open by salines ; sulphate of magnesia and soda are the best. They should be given three times a day, and the dose regulated so as to obtain one or two free actions daily. Purgation should be avoided. Blisters, or a liniment of iodine applied to the ovarian region, re- lieve the pain. The relief, however, is often only temporary. The production of an eschar or ulcer on the cervix of the uterus by the application of potassse c. calce is said to be of service. In some cases relief is obtained by wearing a Hodge's pessary. This is doubtless due to the action of the pessary in keeping the ovary and uterus at rest. It will be found that the above means will effect a cure in a great many cases, more espe- cially in those in whom the ovaritis can be traced back to labor; while in the majority, if not in all, of those in whom the ovaritis is dependent on primary dys- menorrhea no means will be found to effect a cure, and the most we can hope to do is to arrest the course of the disease or ward off the onset of those nervous symptoms which mark it in its later stages and which render the patient a complete invalid. [Prolapsus of one or both ovaries is of not very infrequent occurrence. During the menstrual nisus, there is evidence of a physiological turgescence of the ovaries; and this causes their descent to a lower position. When the abdominal and pelvic parietcs are relaxed, or the normal period- ical ovarian erethism becomes converted into a chronic congestion, the organ or organs may continue to be displaced. "Causes of this affection appear to be : imperfect return of the abdominal and pelvic walls to their normal condition after parturition; sympathetic engorge- ment of the ovaries in connection with chronic metritis or "irritable uterus;" sterility, or frequent, incomplete, and unfruitful sexual intercourse ; excess in venereal indulgence ; and masturbation. Sometimes the ovary descends into an inguinal, or, more rarely, an umbilical hernia. The symptoms are, pain in walking, and still more at the time of defecation; sometimes, pain whenever the rectum is occupied with feces; pain in the act of coition ; and attacks of pain in one or both groins, according to the single or double nature of the dislocation. If one ovary alone descend, it is generally the left. By digital examination, the displaced ovary may be felt, on one side of the uterus ; pressure upon it causes a sicken- ing pain, like that produced in a man by pressure upon a testicle. Dysmenorrhcea is a common accom- paniment of ovarian prolapsus ; and so is menorrhagia. Lowness of spirits very often attends it. In the treatment of this affection, Dr. Goodell' advises the daily use, for a con- [' See a Lecture on Prolapse of the Ovaries, Medical News and Library, Philada., Nor. 1870 ; from which the above account of this disorder has been condensed.—H.]
    siderable time, of the knee-breast position, j digitalis; also, such tonics and alteratives with rest in bed for some hours after it. J as the general condition of the patient Internally, remedies are advised which may indicate. Locally, an elastic ring tend to lessen uterine and ovarian con- I pessary may generally be worn with ad- gestion ; as bromide of potassium and | vantage.—H.] OVARIAN TUMORS. By John Williams, M.D. The ovary is composed of two histolog- ical structures—an epithelium and a vas- cular stroma. The first appearance of the organ, according to Waldeyer, is a thickened layer of germ epithelium, in- vesting an outgrowth rich in cells pro- jecting from the interstitial tissue of the "Wolffian body. By the increase of these two structures, and their reciprocal growth, the mass of the ovary is formed. In the course of development the epithe- lium dips into the stroma, and processes of the latter grow into the epithelium. In this manner epithelial tubes and in- growths of epithelium are formed in the stroma. The tubes are called the tubes of Ptliiger : they at first open on the sur- face. As the stroma grows the tubes be- come closed, and the ingrowths of epithe- lium separated from the superficial layer and its processes. In this manner iso- lated masses of epithelium become inclosed in the meshes of the ovarian stroma. These masses develop into Graafian folli- cles—the change being completed early in infancy. Foulis does not admit the ex- istence of Pfliiger's tubes and their devel- opment into Graafian follicles, but believes that the germ corpuscles which are im- bedded in the stroma become ova, that the Graafian follicles are the ultimate meshes of the stroma formed by the growth of the "connective tissue around the developing primordial ova," and that the "connective tissue corpuscles in the walls of the follicles in contact with the yelk develop into the corpuscles of the membrana granulosa." Whichever of these views be correct, we should natu- rally expect that the new growths formed in an organ possessing the structure de- scribed would often possess a cystic cha- racter ; and experience does not disappoint the expectation, for by far the greater number of ovarian tumors are cystic. Varieties.—Tumors of the ovary may be benign or malignant, solid or cystic. The soiid and malignant are, however, rare. Ovarian Cystic Disease. Ovarian cystic disease is clinically di- vided into simple unilocular cysts, multi- ple cysts, multilocular cysts, and dermoid cysts. Pathologically a similar division holds—the two first being comprehended under dropsy of the Graafian follicle. Dropsy of the Graafian follicle, hydrops folliculi, is the simplest form of ovarian cyst. It does not usually attain a large size. Such cysts are often not larger than a cherry ; sometimes they attain the size of the foetal head ; and occasionally, but rarely, become so large as to fill the abdominal cavity and stretch the abdomi- nal walls. When small they have a structure similar to that of the Graafian follicle ; a fibrous coat derived from the stroma of the ovary—an inner coat on which the epithelial lining is placed, cor- responding to the tunica propria of the follicle. Their contents are a clear fluid, and the ovum has in some instances been found in such cysts. As the cyst grows its walls become thicker and firmer, tougher, and more opaque. In thickness they vary much in different parts of the same cyst, as well as in different cysts. "In some parts the wall may be extremely thin, while in others it may attain a thickness of one inch. Cysts of this nature have been found in the ovaries of children—even in those of the new-born—as well as in those of adults. In the foetus and child the condi- tion is evidently due to hypersecretion of the fluid of the follicle, for at this period of life the Graafian vesicle contains little or no liquor folliculi. In the adult it may arise from the same cause. In many cases, however, it appears to be the result of some condition which prevents the rupture of the mature follicle and the es- cape of the ovum, such as thickening and induration of the coats of the follicle, in consequence of inflammation, and, it has been said, of congestion and hyperemia. Such cysts may moreover be developed from a ruptured Graafian follicle, or from
    a corpus luteum. Rokitansky says that cysts formed in this manner are "always lined by a stratum thicker than the wall of the follicle itself, which adheres to it either very loosely by delicate areolar tissue, or very intimately by a dense con- nective tissue. This lining stratum is of a dirty white color, and has a rough inner surface. It may be recognized as the yel- low layer of the corpus luteuin which has been rendered thinner by expansion, and the roughness of its inner surface is occa- sioned by some of its remaining folds." Several Graafian follicles in the same ovary may undergo cystic transformation, and form a multiple cj/stic tumor. The in- dividual cysts of which such a tumor is formed possess a structure similar to that of simple cysts. As they grow and en- large, one usually takes precedence of the others; they approach to and exercise mutual pressure on one another. In con- sequence of this pressure atrophy and absorption of the walls of the cysts takes place, and a communication is ultimately established between neighboring cysts. As growth proceeds, the aperture of com- munication gradually enlarges, its bor- ders retract and become less and less prominent, until finally two cysts com- pletely merge into one, the only evidence remaining of the original condition being a slight ridge on the inner surface of the resultant cyst, or a slight thickening of its walls marking the line of union of the walls of the original cysts. As this pro- cess affects the primary cysts in succession they gradually become merged into one common cyst. In the course of this pro- cess the tumor may assume a multilobular character, and it often presents hemi- spherical protuberances on its external surface, and hollows or sacculations with intervening ridges on the internal surface of its walls, representing the original cysts from which it was formed. Multilocular cysts, compound, composite, proliferous cysts, cystoma, cystoid, or adenoid tumors, have a very different structure. They are rarely single-cham- bered. In some instances they are formed of one large cyst, with a few small ones within it. In others the tumor forms a semi-solid mass, so divided into smaller cysts by partitions crossing its interior that it presents in section a honeycombed structure. Every transitional form, from the more simple to the most complex, may be met with. These tumors have been called colloid cysts on account of the character of their contents. Waldeyer calls them myxoid rather than colloid, because the contents of the ovarian cys- toids are never pure colloid, and in order to express the true relation between the cysts under consideration and dermoid cysts : for he says that the inner surface of dermoid cysts has the character of epi- dermis, while the inner surface of myxoid cysts has the appearance and character of a glandular and vascular mucous mem- brane. All cysts of the ovary are covered by peritoneum. This may be natural in character, or it may have become rough or adherent to neighboring structures in consequence of inflammation. It has oc- casionally small villous, or globular epi- thelial growths on its surface. Waldeyer maintains that the ovary is not covered by peritoneum, and that this membrane does not form the superficial covering of ovarian cysts. He believes that the epi- thelium covering the ovary is not the homologue of that of the peritoneum, but that it is a columnar epithelium of a mu- cous character, having the same origin as, and precisely similar in character to, the epithelium lining the Fallopian tubes, with the one exception that the latter is furnished with cilia, while the former wants them. It is in this that he finds the cause of the frequent absence of adhe- sions between ovarian tumors and neigh- boring organs. " Serous surfaces readily become adherent, and epithelial surfaces may become adherent to one another or to serous surfaces; yet in order to effect this the superficial epithelium must be destroyed. So long as the surface of an ovarian tumor is covered by epithelium it cannot grow to neighboring structures, adhesions can only take place after the loss of the epithelium. "When numerous adhesions are present the epithelium is always wanting." Waldeyer states that the villous excrescences on the external surface of ovarian tumors and the vege- tations which protrude in some cases through the cyst wall do not form adhe- sions because they are covered by a well- marked columnar epithelium. Dr. Peas- lee states that the part of the cyst wall formed by the ovary is not covered by epithelium, and that it can be distin- guished by its greater whiteness and lesser degree of vascularity from the part of the cyst which is covered by peritoneum. Foulis however does not agree with the observations of Waldeyer upon this point. He states that the epithelium of the hu- man ovary at six and twelve years of age I consists of small flat hexagonal corpuscles, I and regards it as homologous with the i peritoneal epithelium. The walls of the large cysts are separable into two layers, one external and one in- ternal. The wall—especially the external stratum of it—of the principal cyst in- cludes all the secondary or daughter cysts. It varies much in thickness. The exter- nal layer consists of tough fibrous tissue with very few cells ; the internal layer is I softer, more fleshy-looking and vascular, j is composed of fine fibres with an abun- ! dance of cells. The walls are highly vas-
    cular ; the veins especially are large, and are seen in great numbers under the peri- toneum. The arteries lie deeper and penetrate to the inner surface, where they anastomose freely. They are of large size, and possess thick walls, and in some in- stances, according to Wilson Fox, retain the twisted or corkscrew-like appearance, which characterizes those of the ovarian stroma. The epithelial lining of ovarian cysts presents a variety of characters. It lines the whole of the internal surface, and forms usually a single layer of cells. Ac- cording to Wilson Fox, the shape of the individual cells is usually a flattened poly- gonal approaching more or less to the cir- cular form. In other cases they have a more flattened form, and are hardly dis- tinguishable from the elongated cells of the connective tissue beneath. In other cases, according to the same authority, the epithelium assumes a stratified cha- racter, and forms several layers. In all the cases examined by Waldeyer it formed a single layer of cylindrical cells. Ciliated epithelium has been met with on the inner surface of cystoids by Virchow and others. The walls of the smaller secondary cysts are formed of the inner layer only of the chief cyst wall. According to Waldeyer it is a tunica propria like that of the Graa- fian follicle in its early stage of develop- ment. The mode of development of ovarian cystoids is still a subject of discussion. It was at one time thought that all ovarian cysts arose from cystic transformation of the Graafian follicle, and Dr. Wilson Fox, in an elaborate memoir published in the Transactions of the Medico-Chirurgical Society, lias shown how the most complex cystic structures may arise from the ! Graafian follicle by the development of certain growths from its inner surface. He describes three such growths—the papillary, cauliflower or dendritic, the villous, and the glandular. The simplest forms of papillary growths are small club-shaped elevations on the inner wall of the cyst; they are first com- posed of a hyaline finely striated tissue, with many elongated nuclei. They are covered by epithelium, and contain loops of vessels. These growths increase in size, and give off similar processes from their surface, and thus give rise to large composite masses. They are exceedingly vascular, their vessels being of a large size. They are solid, and now the central parts are fibrous, and the superficial hy- aline, there being a gradual transition from the former to the latter. They may J form over large portions of the cyst wall, | or over small portions only. These growths give rise to formations of cysts in the fol- lowing manner: As the papillai increase in size adjacent growths approach one j another, and their surfaces come into contact at different parts. At the points of contact they unite, and inclose spaces lined by epithelium similar to that cover- [Fig. 100. Papillary Growths in a Cyst. (Emmet.)] ing the papilla? and lining the principal cyst. These spaces are the commence- ment of secondary cysts. They may be found at the bases of the papilla?, or be- tween the processes developed from them. They are of various and irregular shapes, but become round as their walls become distended by the accumulation of the se- cretion from their epithelial lining in their interior. The walls of such secondary cysts may develop papillary growths simi- lar to those by means of which they were formed. These growths may form on their inner or outer surfaces, and may give rise to the formation of cysts in a manner similar to that already described, and these tertiary cysts may give rise to another formation of cysts by a similar process. Such multiplication or breeding may go on indefinitely. Villi are very frequently found on the inner surface of ovarian cysts. They may be scattered over the surface or ar- ranged in dense clusters. When scattered they do not attain a large size, and are often branched. They are covered by several layers of epithelium, which tends to assume the columnar form. When densely crowded together they give rise to the formation of tubular structures or cysts like the glands of the stomach. The first indication of the formation of
    villi is a stratification of the epithelium ] lining the cyst. Into these stratified masses of cells processes of the inner lining of the cyst containing a loop of vessels grow. In this manner a series of papillae are formed with hollows or pits lined with epithelium between them, i which are converted into tubular glands by a growth of the connective tissue of j the stroma between the papillae and j around the hollows. As the stroma grows upwards between the papillae the tubular I glands deepen and become more and more j imbedded in the cyst wall. Vessels sprout up into the walls of the glandular tubules, and anastomose with those of the villi, forming arches at various depths of the tissue. These glands rarely multiply by lateral diverticula. A very common mode of increase, however, is by enlargement of the base of the gland, and a develop- ment of vascular papillae from its centre in a fashion similar to the development of the primary villi. These papillae may form tubular glands, and by a repetition of the process in the same gland its cavity may become subdivided by a series of septa into several tubes, all having a com- mon outlet. [Fig. These glands may form cysts in various ways. The orifice of the gland may be- come closed by pressure on its sides ; ad- hesion may take place between the touch- ing surfaces, and the opening become sealed ; or the gland may become dilated into a series of cysts, or follicles, across which septa may grow from the thickened walls and completely separate the several follicles, converting them into cysts; or the stroma of the ovary may grow up- wards to such a degree as to include the whole of the papillae, and inclose the whole of the gland in its substance. This would give an appearance of the development of glandular structures within the walls of the cysts. Indeed, in all cases in which the stroma of the wall has grown upwards between the papillae, an appearance of the growth of glandular diverticula from the inner surface of the cysts into the substance of its wall is brought about. Dr. Wilson Fox, however, believes the above to be the true explanation of the process. Dr. Fox describes another method in which multiplication of cysts may take place. The cysts produced in this man- ner are transparent, and possess very 101. Papillary Projections after Rupture of a Cyst. (Emmet.)] thin walls. The process is similar to that by which diverticula or buds are given off from glandular structures. Hollow processes,"having a flask-shape appear- ance, grow from the wall of the cyst. These processes have thin walls; their orifices of communication with the parent cyst are very fine and narrow; but their canals immediately expand, so as to form flask-like sacs. They are lined by poly- gonal epithelium, continuous with that lining the parent cyst. In this manner a multiplication of secondary cysts may go on indefinitely. Such secondary cysts, as they increase in size, may come in contact with one another, or with the walls of the parent cyst; union may take place at the points of contact, and several