of being evacuated through the trocar than are the contents of the more condensed and undeveloped cysts of the tumour." Intercommunication of Cysts.-In a congeries of cysts much mutual pressure is exerted; and from activity of secretion in some, whether by inflammatory action or not, such compression may follow, as to cut off the supply of blood to others, and so arrest their growth. This is illustrated where one cyst appears to grow at the expense of another. Compression will likewise cause the softening and absorption of intervening partitions or septa, and throw two or more sacs into one. So also the secondary cysts of endogenous growth may open into one another, and the entire tumour be resolved into one of few cells, or even into a single cyst. The intervening walls are sometimes not entirely destroyed, but are represented by remaining bands traversing the cavity of the false unilocular cyst. This deliquescence of several cells into one is more common with those of endogenous origin and small, than with others; for mostly where there are several large sacs in compound encysted disease, they do not communicate with each other. The very reverse of this process of breaking up of several into one cell, is exhibited in that endogenous development in a simple sac, which thereby becomes converted into many, probably, as above intimated, to be reconverted ultimately into a single one. The expansion and compression of adjoining cysts lead to active inflammation, to the effusion of pus, and sometimes to actual gangrene of their walls. The inflammatory process, when set up in an ovarian cyst, whether simple or compound, frequently extends to its peritoneal surface, and thence to organs contiguous. The inflammation of its peritoneal coat leads to thickening and opacity, and mostly to the effusion of lymph, which causes it to adhere to some adjoining part. Either inflammation may extend from the cyst itself to some neighbouring tissue, or the irritation of the cyst may set up that process independently in the tissue, and not unfrequently peritoneal effusion be poured out. The adhesion of the cyst to surrounding parts, although an impediment to extirpation, sometimes favours a natural cure by rupture. Adhesions on the posterior surface are very rare, and not to be discovered by examination. It is to inflammation, acute or subacute, within the cysts of an ovarian tumour, that their rapid increase in size is mostly due; and from it also often result the breaking down, or perforation by ulceration, of septa between cysts, and the rupture of the tumour. This morbid process produces indeed the same changes in the lining tissue of a cyst, as in a normal serous cavity, and effusions of a like character. Communication of Cysts with the Fallopian Tubes.-M. Richard, of Paris, citest four examples of cysts, simply ovarian in origin, which "had involved a considerable portion of the Fallopian tube, through which their contents could by pressure be forced into the uterus. The portion of tube implicated had become much increased in length and thickness, and the folds of its mucous membrane, which are so numerous and resistant, were partly effaced. A distinctly formed aperture was the means of communication between the ovarian cyst and the tube, through which the contents of the former could be forced. Although, however, the portion of the tube which remained in its normal state offered no physical obstacle to the further passage of the fluid, this only passed out, even in small quantities, when a probe was introduced and pressure was applied, the latter alone not sufficing. M. Richard believes that some of the cases described as tubar dropsies,† have been in reality examples of this occurrence (which he calls tubo-ovarian), and that in this way may be explained the course and disappearance of some encysted abdominal tumours." Contents of Ovarian Cysts.-The physical and chemical characters of the contents of ovarian cysts vary very much in different cases; and where the tumour consists of several sacs, i. e., is multilocular, they often differ much in the various cells. The contained fluid is frequently like the serum of the blood, of a pale yellow, or straw colour, but containing only a trace * See Medico-Chirurgical Review, April, 1854, p. 465-in Analysis of the "Mémoires de la Société de Chirurgie de Paris," by Mr. Chatto. See subsequent page on Dropsy of the Fallopian Tubes. of albumen. Secretion of this kind is, according to my experience, the rule in unilocular cases, or in those having but few cells, and of not long standing, and not previously punctured. This pale liquid may also be limpid, or be mixed with more or less mucous matter, sometimes in quantity sufficient to give it a gelatinous or ropy consistence. At other times the cystic fluid is coffee-coloured, or thick, as if mixed with coffee-grounds; and when like this, has been by some considered peculiarly diagnostic of ovarian disease. This variety likewise will sometimes be met with in ovarian tumours when first tapped, and may recur; but it appears oftener after the first tapping. The peculiar colour may be assigned to the presence of altered blood. The dark-coloured gelatinous fluid sometimes discharged, is most probably derived from the gangrenous softening of the internal septa of the cyst. I have met with opaque contents, of a yellowish-white colour, which under the microscope appear to consist almost entirely of fat-globules, and which, when allowed to stand, form a semi-solid, greasy mass. Cysts containing such matter seem to be accompanied in their formation by unusually great pain and disturbance of the system. Occasionally I have evacuated from a cyst a black, ink-like liquid; at times a gruel, or custard-like one; and, in some instances, a mixture of fluid with semi-solid, brain-like matter. After tapping, an unhealthy state of the sac is apt to ensue, and an ichorous, or putrid, fluid escape; or purulent matter form and discharge, with or without fetor and gases from decomposition. But pus also occurs in unopened sacs from spontaneous inflammation, and also, as Dr. Bennett supposes, from the formation of pus-corpuscles in the gelatinous contents. A cyst, after being once evacuated, rarely again secretes fluid of the same character as before. As above remarked, the very fact of emptying the sac seems to change the character of its secreting membrane. Even if an alteration of colour be not met with, there is generally one in the consistence. The change from a clear to a more or less opaque, or to a mucilaginous liquid, is common on a second tapping. Not unfrequently the transition is still greater, and a second emptying of a cyst produces a coffee-coloured, or gruel-like, or a flaky discharge. The semi-solid, brain-like, and flaky substances may be commingled with either variety of liquid contents. The quantity of contained albumen varies much in the fluid of ovarian cysts. Dr. Druitt* writes, "The contained fluid generally contains about eighteen grains of albumen to the ounce;" but I have met with instances where the proportion has been so great, that, on boiling, the fluid has set almost as solid as white of egg. The excess of albumen I consider an unfavourable circumstance in any case, and one calculated to modify our prognosis and treatment, as pointed out in the subsequent section on diagnosis. It may be stated generally, that an increase of density in the dropsical fluid, (associated as it is with an augmentation in the animal and saline constituents,) whether that increase manifests itself by a mucilaginous consistence, a more plentiful production of flaky, or gruel, or brain-like matter, betokens a more depraved or morbid condition of the cyst, and indeed of the general health, and consequently a condition less amenable to cure. However, I am disposed to believe that, in some few cases, such a morbid change may take place in the secreting membrane of the cyst, from the effects of great distension or of pressure, and of repeated paracentesis, that its secerning powers may be to a great extent, or perhaps entirely, lost, and the cyst consequently remain as an inert mass within the abdomen. An instance of this nature was, I think, presented in a case of Mr. Bryant. † On the occasion of the third tapping, a fluid of the consistence of gruel was evacuated, having to the eye a near resemblance to a purulent discharge. Subsequent to that time, the previously enormous sac remained nearly inactive, with dimensions greatly shrunk. If this view be correct, some prospect of benefit is attainable even in cases otherwise desperate. Besides albumen, chemistry reveals other constituents in ovarian fluid, as fatty matter, cholesterine, and various alkaline salts, chloride of sodium, sulphate of lime, and soda, &c. An *The Surgeon's Vade Mecum, sixth edition, 1854, p. 465. old analysis, by M. Jules Fontenelle,* detected, in eight pints of brown and turbid fluid, 6 parts of fibrine, 97 of albumen, 34 of congealed gelatine, a little phosphate and chloride of sodium. Under the microscope are seen various small corpuscles, and numerous large and compound cells filled with granules, together with fat-globules and delicate plates of cholesterine. Dr. Hughes Bennett† states that "the flocculi often floating in ovarian fluid, are patches of epithelial membrane, more or less united together by granular matter. Sometimes it is filamentous, with granular cells and other products of inflammation. The jelly-like matter, when consistent, presents all the characters of coagulated liquor sanguinis." In considering the diagnosis of ovarian dropsy, I shall have again to refer to the microscopical as well as the chemical characteristics of the fluid, and will therefore here enter no farther on the subject. The quantity of fluid which may accumulate in an ovarian tumour is certainly astonishing. As much as 120, and even 140, pounds of liquid are recorded to have been withdrawn from one sac. In a case I have described, I drew off 93 pints at one tapping. Moreover, it is well known that a cyst once emptied secretes more rapidly than before. The last case quoted shows this. The first enormous quantity removed was the result of four years' accumulation; but, after its discharge, 49 pints were secreted and evacuated within two months, and a further 52 pints after the lapse of little more than three months. History affords many instances of this rapid and repeated production of ovarian fluid, when paracentesis was generally the only method of relief attempted. To quote one or two in illustration, "Mr. Martineau drew off nearly 500 pints in a twelvemonth; and from the same patient upwards of 6600 pints by eighty operations, within twenty-five years."§ Dr. Copland adds, "In a case under the care of my friend, Mr. * Archives Générales de Médecine, Tom. IV., p. 257. + Edinburgh Medical and Surgical Journal, Vol. LXV., 1846, p. 40. Lancet, Vol. II., 1849, p. 9. Copland, Dictionary of Practical Medicine, Vol. I. p 664. |