CHAPTER XXIX.

CYSTIC TUMORS OF THE OVARY.

THE histogenesis of cystic tumors of the ovary is not yet definitely settled. Every structure that enters into the composition of the ovary has been supposed to form the starting-point of these tumors. There are many classifications of ovarian cysts based upon the clinical, structural, or genetic features. The classification given here seems to me to be the best we have at present for the practical physician.

Kobelt's tubes

Parovar

Gartners duct

Paroophore

Oophoron

FIG. 161.-Diagram representing the cyst-regions of the ovary and broad

ligament.

Cystic tumors of the ovary may be divided into two general classes:

I. Oöphoritic cysts, which originate from the oöphoron, or the egg-bearing portion of the ovary.

II. Paroöphoritic cysts, which originate in the paroöphoron.

OÖPHORITIC CYSTS.

Cysts of the oöphoron may be subdivided into (a) Follicular cysts; (b) Glandular cysts; (c) Dermoid cysts.

Follicular Cysts.-Follicular cysts originate in the ovarian follicles. If anything occurs to prevent the physiological rupture of a mature ovarian follicle, a follicular cyst may be started. Such cysts begin as retention-cysts of the ovarian follicles.

The condition is usually the result of chronic inflammation. The formation of new connective tissue in the ovarian stroma, the thickening of the tunica albuginea,

the presence of inflammatory exudate upon the surface of the ovary, may all prevent the rupture of the follicles. In addition, the inflammatory congestion of the walls of the follicle produces an increased exudation into the ovisac.

It seems probable that such inflammatory action may also produce cystic distention in the immature follicles. that are situated remote from the surface of the ovary.

Follicular cysts may occur at any age, though they are most common during the period of sexual activity. The

follicular cysts may occur in one or in both ovaries; usually both ovaries are affected.

Only one follicle may be involved, or a large number of follicles, in different degrees of cystic distention, may be found scattered throughout the ovary.

Frequently one follicle enlarged to the size of a hen's egg is observed projecting from the surface of the ovary. Sometimes the intervening septa atrophy, and one large cavity is formed by the union of two or more cystic follicles.

Follicular cysts of the ovary do not increase indefinitely with age. They are limited in growth, and in this respect differ essentially from the glandular oöphoritic cysts. They are usually about the size of a hen's egg. They rarely attain a size greater than that of the adult fist. Exceptional cases have been reported in which the ovarian tumor was the size of the adult head. The tumor may be composed of one chief cyst-cavity, while the rest of the ovary may present a much less marked degree of cystic distention; or a large number of follicles may be uniformly distended each to the size of a cherry, forming an ovarian tumor as large as a child's head.

When the ovarian follicle becomes distended the walls. usually increase in thickness and strength.

The interior of the cyst is smooth. The character of the lining membrane varies with the size of the cavity. In small cysts it is the membrana granulosa-columnar epithelium. In cysts of medium size the cavity is lined. with stratified epithelium. In the largest cavities there may be no epithelium present, the lining membrane being fibrous tissue.

The follicular cyst is usually filled with clear serum. having a specific gravity of 1005 to 1020. It resembles normal liquor folliculi. The fluid may be purulent as a result of septic infection, or it may be brown or black from the presence of altered blood. Ova are sometimes found in follicular cysts of moderate size. Sometimes hemorrhage takes place into the follicular cyst, form

ing a follicular blood-cyst, which may attain the size of a man's fist.

Cyst of the Corpus Luteum.-A variety of the follicular cyst is the cyst of the corpus luteum. Such a cyst is formed by the degeneration and cystic distention of a corpus luteum. These cysts are usually of small size, rarely exceeding that of a walnut. The walls are thick and of a characteristic light-yellow color. The cavity is lined by a delicate membrane. Cysts of the corpus luteum are rare in the human female, but are very common in some of the lower animals-the cow and the

mare.

The symptoms caused by follicular cysts are those of pressure and ovarian pain. The cyst may become impacted and adherent in the pelvis, and may cause pressure. The ovarian pain is analogous to that described under Chronic Oöphoritis. The pain that accompanies this form of cystic tumor of the ovary is much more marked than in the case of the larger kinds of ovarian cyst, which may be unattended by any ovarian pain whatever. In some cases follicular cystic disease of the ovaries is accompanied by menorrhagia or metrorrhagia which is only relieved by oophorectomy. This symptom, however, is not usual.

The diagnosis of the condition is made by bimanual examination and by observation of the clinical course of the disease. The cystic disease is very often bilateral. The ovarian enlargement is slow in development and is always limited. A moderate maximum size is reached and may persist for years.

Treatment. The only curative treatment of follicular cystic disease of the ovaries is by operation and removal of the tumor. Operation is required only in those cases in which the suffering is great. The mere presence of the cystic ovary does not demand operation, whether it causes physical suffering or not, as in the case of the cystic tumors hereafter to be considered. It must be remembered, however, that it is often difficult or impossible

to make a differential diagnosis between follicular cyst of the ovary and a young glandular or papillomatous cyst, and it is very much safer in all doubtful cases to adopt the operative rather than the expectant plan of treatment. If, after the abdomen is opened, the cyst is found to be follicular, the ovary need not necessarily be removed.

If, at the time of operation, the ovary is found to present but one follicular cystic cavity, this may be opened and evacuated and part of the wall may be excised. If bleeding occurs from the edges of the cyst-wall, it may be controlled by whipping with a fine continuous suture of silk or catgut. Some operators avoid this bleeding by opening the cyst with the cautery-knife. In any case the bleeding is usually slight if a thin portion of the cystwall is selected for the incision. If the ovary is filled with a number of cystic cavities, it is safest to remove the whole organ. If the woman be young and anxious for children, the small cysts may be individually incised and the ovary returned to the abdomen. This latter proceeding is especially desirable in case both ovaries are diseased. When but one is affected, the surgeon need not hesitate so much before performing oöphorectomy.

If, as is very often the case in cystic disease of this character, the Fallopian tubes are found closed by inflammatory adhesions, salpingo-oophorectomy is usually indicated.

Glandular Cysts.-Glandular cysts are also called multilocular ovarian cysts or ovarian adenomata.

It was formerly thought that all ovarian cysts originated in the Graafian follicles. This view has now been given up by most pathologists. The follicular cysts that have just been described never attain a large size, and run a distinctly different course from the glandular cysts now under consideration.

The glandular cysts probably originate from the tubes of Pflüger. It will be remembered that in the embryo the ovary contains many epithelial tubules derived from the germinal epithelium that covers the surface of the