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Las diagrammas 'uiva.-its illustrant la mAthoda. 1 2 3 1 2 3 4 (II 6 4 An Extra-Abdominal Multilocular Ovarian Cyst THOMAS S. Cirr. LKN. M.D. BALTIMOKE Keprinted frm The Journal of the American Medicat Attoctation Oct. 14. »», Vol. LVIl, pp. asi-tiis COPIRIOHT, 1011 AMKHirAN MEHIl'Al. AaS(>CIATH>N KlVK IlrMIBKI) AND Til IIITV-KIVE IIEARBOIIX AVENUE J'HirAGO .VN EXTRA-ABDOMINAL MULTILOCULAR OVARIAN CYST* TIIOAIAS 8. CULLEN, M.D. DALTIMOIE Several niontlir* ago, Dr. Frank R. Smith asked me to see a woman who had a kidney-shaped tumor slightly below and to tlio right of the umbilicus. The patient had noticed a small lump in this situation several years before, which for a long while had remained nuiescent but during the last year had gradually increased in size. At operation it was found to be a partly solid, partly cystic tumor of the ovary lying external to the abdom- inal mustles, the tumor and its surrounding sac being covered over with a small amount of adipose tissue and the skin. The pedicle of the tumor passed through a hernial ring to the outer side of the right rectus and obliquely across the lower abdominal cavity to what corresponded to the normal insertion of the right utero- ovarian ligament. I have been unable to find any reference to a similar case in the literature. History.— yit». M. W., aged 56, was a short, well developed woman, and. apart from a tumor mass in the lower abdomen, wa» in excellent health. She had had eleven children. Her periods had ceased at 50. She had felt some pain in the right ovarian region for fifteen years, and for about ten years she had noticed a little tumor situated in the right lateral ab<-iii I (imiikI that flip iitt-riiit whh noriiml iiiiil tlmt there wiiH no thirkmiii'; hitt>r«ll,v. Not being KUre of the exact I'onilition, I tiiadt- a nifiliaii Inciiiinii. Th<* iiterii* wan iiorinal. thi- left tuU- ami ovary prt-nenteil the iixiial Mp|M>aranci'. The rifiht lulie Khdweil no i-haiif((>. Iiiit the right utern-ovarlan liga- ment wan niarkiHlly dra -n out into a Uind nlmut I cm. bruad. ThU Inl to a hernial o|>ening with Hmooth margimi in the right lateral aUlomlnal wall In-Iow and to the riglit of the uii>biliciiii. but at leaHt I'i rm. from the inguliMl region I Kig. 1). After obtaining giHxl e.\|M>iiure I found that thin tiattenetl band of the utiro-ovarian ligament pa»>ieneath the xkin in the adipoae tiHnue, and waf* very eaHily fretnl by blunt dii4Nertion to the |ioint where tin- hernial ring entered the abtlonKii. I then cut the peritoneum around the hernial ring and delivered the tumor, with itH |>eritoncel covering intact. The Kjiaie where the tumor had existeeritoneum. wliicli could lie read- il.v separated from it. Here and there attached to the outer surface of the peritoneum were tags of adipose tissue. The tumor itself was in large measure solid, resembling a fibroma. It pre^iented a lobulated ap|>earttnce. Here and there lietwecn niHlules it showed cystic spaces, ubiong. irregular, or round, varying froiu 2 mm. to 2 cm. in diameter. The majority of tliese were transparent an-l contained clear tluid. Some of tlieni were slightly bloisl-tinged. So much could he made out througii a window, which was cut in the peritoneum. On peeping in tlirougli the hernial ring, were seen cysts varying from 2..'> cm. to I! cm. in diameter and apparently fllleil with clear fluid. Al'ler the ( the tumor connUti-il In larifc purt uf lllirouo tUiiuv mntHininR triangular or apinilltfuliaiHil nut'lt^i. In iMinit' plart'* the nurlfi wrrc abun- dant, in othprx scanty In niinilirr. The tiriiiu(> RlioMml a vim- aiilcrnble tjpgrec <>( hyaline .li,ienrration. At unp or Ivto |M)intii rliarai'lrriiilii- ovHriaii atrnnM wm> xtill in t>vi(|>-nre. No Graallan fullicle^ toulil be founti, but after an examination of numerouK •••H-tionn a typical cKrpi.s flbrtwiim wb« noted. In w)nie Dt'i'ticin* a few hundUn of ii.y «lri|>eii|;vr blly except in a few aieas, where there were |iruu|>-< of rather large veins. Sraltercd »|>nrini(ly through the stroma were small circular or irregular glandt iiecurring singly or in groups i f two or three. They were found to be lineration, and in e few liquefac- tion of this hyaline material had taken place. Even in some of the larger cysts a moderate amount of fresh blood was present. The stroma cells beneath the cyst epithelium had in some places become swollen and spherical and were filled with yellow or brown ]>igment indicating the absorption <>f blood lit tome previous time. On the surface of the tumor were ii moderate number ■ >h8- culai .idhesions, and on the under and protected side (< these the peritoneal cells had become cuboidal aa i :'omni'> in the under side of tubal or ovarian adhesions. From the above description it will be seen that the dense matrix of the tumor consisted essentially of fibrous tissue and that scattered throughout this were multiple cysts, in large measure similar in character, some of which had small papil- lary masses projecting into them. Had the tumor developed in the abdominal cavity, I believe that in all probability it would have bei-n a multilocular cystomo. but as it lay between the abdominal muscles and skin a rapid cystic growth was much more ilitlhiilt, uikI Hi.- Ill>r ti*«iie wh» lhii« allowml In ki^p |>nif with till- i-y»lii' fiirniHtioii. 'I'liiTP HHK iinr»itiilur intircxt in tliix (oniiwtioii. I shall. llnTt'forf. l)ri»'Hy tlimiiM tlit- iiion- iin|Nirtaiit ton- triltutiono nmdi' in tliJK fifid. . Ilitv! "..■*"'■*" ' *:0"LE rAHHINO KROJI fTEBlH, OUT TllHOfdll H. n ,?f ft'' '"i"! '^■'"i■ -^""'"'XA'- Wall. A xohemntlc repri-nentn- tlyn of thp pplTlo »lru imaned tompletely around this pedicle. It r„Hi ?,""'?.,''''* '"''IT'",'" "'» ring. A glance at the umblllcua will Indicate the exact lo nn iti^^iiiaal or feinurnl hernia vxittt* tlir uuiry nml ntten the tiil>« form part of tlR> conti'ntH of tlif iif! nml .«iir. I'liwh' m 1H7!I i nn- trihutctl a infi>ni to tlwuic of Pott. I^iitNUi), IhMicux, (tiu'ruant. I'arkcr, Brun , War- ren, MeadowM, Cukco, t'oote, Knulinrh, Weinjechner, MacCliicr, Monni'nburjr, Worth anil Hlu'indtaedter. In brief his pajM'r »ayn that the ovary may pass out at any of th<' natural aiNlominal opi>nin>;i«, ami that, when it doe» HO, it i* niont fre(|Ui'ntly l>y way of tin- femoral or in|;uinal nn^i. The in;ruinal hernia, whieh in the more fre<|uent, may U- eonftenital or accidental. The con- 'Mo; inalof;ou8 to y-eij{ht eases of iir were inoontcst- and seventeen acci- werc unilateral in genital hernia is produced by the descent of the testicle, hernia containing the ovary, ably congenital, seventeen dou!. . dental. The 'ongenital hernias twenty-seven cases, bilateral in twenty-seven cases In the unilateral cases the left side was more frequently involved. In cases of double hernia the presence of the ovaries in the hernial sac was sometimes associated with defective development of the generative organs. Puech ha«l records of sixteen cases in which the ovary was contained in a femoral hernia. In eleven of these cases the hernia v*as on the right side and in four on the l.'ft. The uterus or one of its corrua was found ten times in the sac in cases of inguinal hiTuias, three times among the femoral hernias. Dr. Jof ^h C. Bloodgood tells me that he has had two caseF 'emoral hernia with the o\ary lying in the hernial sa. rJevo'-al tears ago I operated on a child in Cambridge fi-i- an inguinal hernia. The sac contained the right t:' p and ovary. They were so intimately blended with th '^.iC that it was impossible to save them, and they were removed preparatory to doing a radical operation.' 1. Puech, A. : Nourellci rechercb'^ lur loi bcrnlei de l'oTalr«, Ana. de gjnfc., Fkrii, 1870, xl, 401. 2. Thl( niie wai reported and lllnitrated lo an article pabUshed by Dr. Prank T. Andrewa (Hernia of tbe OTary and Tube, The JorBNAL A. M. A.. Nov. 24. 1908. p. 1707). Dr. Aodrewi' article kIti's nn I'xcellent r^aumf of hernia of the ovary and tube, und Ilkc- wUe contatna a long tabulation of caiei heretofore obserred. (i My exp,Ti,.nce with ovaries in l.erni.il rinps associ- .;. w. i, aok of .levolopmont of the crener.tive organs m> heeu limited to one fase.'' A posti.|x.rativc hernia occasionally contains an ovarv 'ke'CV^ /'/'r; "l *''■' ^•'""•..-ter- several years apo> I he patient iia.l had an appendix ahscess. whicli it had .en necessary to drain liberally. The resultant hernia in the scar was very tender and in .lissectin? it out 1 fonn.l hat the sensitiveness was due t.. the presence of the right ovary contained in and adherent to the hernial OV.VKIAX Tl-MOllS WAKUmyG IX THE INGCINAL CANAL Since one or hotli ovaries may occasionallv be found •" tbe ugmnai canal, we shonhl not be surprised to find ';•«■ "... then a case in which such an ovary under.-^s ..nor development. ISheinstaedtei- in 187« repoS t 1 f ! '■ '" *'"' "e.ghl,orhoo.l of the clitoris In addition, here was a riglit-sided globular mass, which w.> tound to be a right inguinal hernia. The ova """.'.•^vas larger than a chil.rs head. ela.stic and appiJ v «..<■ tiiant. The overlying skin was normal ""I'able diagnosis of ovarian tumor in a left in-uinal H' 'ma was made. Six months later the left hernh, si^ «as opened. The tumor was easily rni.od and its roa^ - nicnt wa. tied off, some adherent loops of small bowel v'umWW "t.'"':'"' "P '"*° the 'abdomen, ind ?h fl.'iHKl Closed. I he tumor weighed 7-50 a,,, Careful examination of the right hernia revealed^ I e pr S 01 the ovarv in the sac. ' >-t:uie di^Inoil"fi!; r''" "'''''^' ^^'^ .i.ie.-o.^opic examination, diagnosed the tumor as an angiosarcoma. ierl wn'^nM 7'i"r'r'"^ ♦'"^' ''■^""ture on the sub- ject. «as able to find only one case in which an ovarian I > i^eigel. i he hernial sac contained a portion of an ;>variancy.st,theremamderof which lay in the pelvi" canals. S„rg. Ci.vnoc. and Obst. Jul" ' 1910 n tT "" *"" ""^""" Fol/o«. n« Ta 'op1?aUon-J''A?^ii:S.°"i ■'"'•'''• -Abdominal Soar o.n4"l!ilL?|J.rr?/4Vce?,'^1K«S^^^^^^^^^ Ovarii ,n it L. ? 4; R B,- ■»=5e2>'5£» -|z!!e ^"o t— 2i t^ a. •°£ =- 5jat« ' =■ 1- = -i t: c *. c *" *- * X "? ■£ P3= . .CC 1 £1? > i- 1 =T X= J- - - - » .tfsl B = fc Z~'- a.*- i t K - V . ' fci *- (K • •— w y Li C J-— « 4,*- li « a t-t-'H SeM ^llfiEff" * S I. a aCS "■" |Sg|aS§i 8 Of solid ovarian tumors i-ontiiineil in hernias he men- tions only a case of Guersant reported by Englisch. Fargas,* in 1890, described the case of a woman, aged 38, who had a tumor the size of a man's head occupying the right inguinal and labial region. On the left side was an inguinal hernia containing an ovary, which was easily reducible. The patient said that until eight years previous the right side had presented the same appear- ance as the left, and Fargas. therefore, diagnosed the tumor as a right-sided ovarian cyst. Six years prior to observation the right hernia had become irreducible, and after that had gradually increased in size. The hernial sac was opened and the cyst lay free from adhesions. Its pedicle was tied off as in an ordinary ovariotomv and the tumor removed. The patient made a good recovery. The cyst was reticulated (multilocu- .lar). Fargas "confessed that it might have been con- founded with a cyst of the round ligament, but its topog- raphy rendered its source certain. The woman had had noniial menstruation and had borne two children dur- ing the existence of this tumor. Seymour' in 18!»; reported the case of a woman aged 48. Two years before coming under observation a small tumor ha(i appeared in the right groin. It was some- what sensitive, hard and irreducible. An inguinal her- nia with possibly an incarcerated omentum without strangulation was" thought of. At operation the tumor was found attached to the uterus by a pedicle, 4 inches long and % inch in diameter. This passed out through the inguinal ring to the under surface of the upper end of the tumor in the inguinal canal. The pedicle was tied off and the sac closed. The tumor was ovoid in shape, 4 inches in length and S inches in circumference. The microscopic report was spindle-celled sarcoma.' (t Karsas : Xotp sitr un ons dp liernle Ingulno-lablale dp Vovoire driiit uvpc (?r»8 kystp rStlculairo du mSnie organp, Arch, do tocol., I'arls, 1800, xvil, T67. 7 Spymour: llornla of a Sarcomatous Ovary, Tr. Med. Soc. StalP of N. Y.. 18!)7, p. 370. 8 If the fibrous character of a solid ovarian tumor U definite, one Is safe In making a diagnosis of fibroma, and If the growth con- sists of spindle cells and has many mitotic figures and atypical cell changes, one can with Justice make a diagnosis of sarcoma. There are however, quite a number of solid tumors of the ovary of the snlndle-cellpd type. In which It Is Impossible to say from the micro- scoDlc examination whether the growth Is a sarcoma or a fibroma. In su.h cases the ulagnosls can npvpr be definitely determined unless the patient subsequently develops metastases. I) AX OVAllIAX CYST IMIOTIUDlXd 1"''0 THE INOUINAL GAKAL BaUly" in 1S98 roportod an interesting case of this charatt'er. Two voars Iwfore coming under Baldy's observation the patient had noticed a small peduncu- lated tumor in the right inguinal region. This had con- tinued to grow until it was as large as an egg and had then been removed. A year later a larger and similar growth had been present and had also been removed. KlK. ."t.— An Extra-Abimimisai, Mixtilocular FibbOCISTOMA. A schemntlo ropreHentatlon <>( thf mannt-r In which the tumor tended to develop when relieved from Its surrounding pressure. It In reality ronslsted of four lob«'» similar In character and Jolneil together by broad or narrow pedicles. When Baldy saw the patient the growth was as large as a list. A pelvic examination revealed a mass filling the right side of the pelvis. At operation, an incision was made directly over the growth and the tumor freed down t o a thick, broad. Baldy, J. M. : Ovarian Cyst Protruding Through the Inguinal Canal, Am. Jour. Obst., 1808, xxxvlll, 827. 10 sliort pi'diik' wliicli ]mss('il into iind tliroiijili tlie injjuiiml iiiniil. 'J'lic attiicliniL'iits of the pi'diclo in tho cnnnl were fiTfd and tlie (iiijicr forced into the ahdonion wIrmi it was found that tiic timior was a continuation of a hir^e intra-alxloniii'.al Tna--. When tho aUdomi'ti was (ipciicd in tho nit'dian line, the iK'diclo of tlio injruiual ;;i'o\vth was found sprinjrinj; from a htrfic intrali-ianiontarv tumor simihir in diarac- tor. The U'ft uterine a]>penih»';es wore normal. A supra\a;:inal hvstere;tomv was iH'rfornied aiul the her- nial rini; closed. 'I'he patient nuido in uninterrupted recovery. AX OVAlilAX CYST I.YrN.J I'AliTI Al.I.V l\ A nCMdlfVL i[i;i(NiA This condition is exceptionally rare. |)(>llhaes"' in ISS.") cited the ease of a woman, a;:od •")•■>. who entered the hos]iital in 1ST!) on account of ascites. For four years she had conii>lain<'(l of discomfort in tho lower alidomen. and there had lieen an increase in size in the ri,;.'ht side. Thereafter she had had a crural hernia on the riirht sid<' and for the last nine months a similar hernia on the left. The riuht was rediicilde, the left irreduciiile. After tho patient liad heen huilt u]t to some extent and after tho ascitic fluid had heen removed several times by puncture, a riszht-sided ovarian tumor, partly solid, jiartly cystic., was removed. The left ovary was cystic and enlarjjed. It was partly situated in the pelvis and had to ho separated from a sidid cord which jiassed into the femoral cnnal. The major portion of the larfre cystic loft ovary lay in tho fold of tho proin and fourteen day. later was removed throi.^rh a herniotomy incision. This portion was as larc:e as a child's head. The ])atient made a complete recovery. A SMAl.I. POKTION OF .VX OVARI.VX CYST IXCAItCEliATKD IX Tin: AHHOXIIXAI. WAI.I. .11 ST HKI.OW TIIK fMHlI.IClS Hopkins" in 1S!I4 re])ortod an intorestinj; cmerirency case. The patient, ajred 'u, was admitted for a sup- l)oscd stran>:ulated nmhilical hernia. Protrudinfr just 10. DfUhaos : F. no Ilt'rnln cniralls evstovarll stnlDtrl, Ztsilir. f. Gpbnrlsh. ii. Gynak.. 18S.'>. xi. .fSft. 11. ll!ii- latcd I'mhiilinl lli'rnla.. lioston Mod. and iSurg. Join.. .Inly L'li, 1S04. p. .H4. 11 below the umliiliciil oiK'nini: was en almost black tumor die size of a walnut. Still thinkinjj that it was a stran- gulated hernia, the niK>rator tut the eonstricting band and the tumor at "nee disappeared. The abdominal openinf: was enlarged anil serous and jielatinous mate- rii'l ix'gan t" pour out. On further exploration a mul- tilocu'iir ovarian lyst, weifrhinjr about 'i't jiounds, was found, 'iiiis was removed and the patient promptly recovered. A small pDition of this cyst had become strangulated in a small hernial defect just below the und)ilicu8. nKFFC'JS IN' TllK AHDOMIN.VI. WAI.l. .V study of the weak spots ; the abdominal wall is of interest. Levadoux'- in.ule a most exhaustive exam- ination of the inner api>earaiu-c of the umbilicus, of the final disposition of Uie um' -ai arteries, the umbilical vein and the unuiius, and ilcscribed in detail how tl.t^se sometimes blended in such a manner as to form a fibrous sheath that completely covered over the inner umbilical opening. In the course of his studies he also noted weak spots in the fascia just beneath tlu ]H'ritoncuiii. These openings were usually small and were oval, round or ir"eguiar in shajH". On i-areful scrutiny it has at times been noted that hernias, su|)posed to be umbilical, were in reality ]ieri- umhilical and that tfie umbilicus itself was intact. These defects in the fascia are undoubtedly the cause of such hernias. In July, 1!U0, I saw. in consultation with Dr. A. II. A. Maye.. a boy, aged IT, who had a small hernial protrusion 4 cm. above and to the left of the umbilicus. This hernial | rotrusion projected 1 cm. through the fascia and was lohulated, forming a mass ;{ cm. in diameter. The patient was of spare build. On cuttinsr down on the hernial sac I found a small defect in the abdominal wall with a small portion of the oinen- uni i)rniecting through it. The omentum was readily retu'-ned and the oitening easily obliterated with a few sutures. Dr. Bloodgood tells me that he ob=ervjd a case of liernia of the abdominal wall at the s inar line, that was between the rectus niuscle and j forming the 12. I.ovadoux, ^nclll'l-.^n»^•^lll : Vi>ili'tt''s ilp I'limblUo <>t
  • ii]iiiiil umI flit lodlis of siiiill' Tl ■I. r ic -ill ( iiiitiiiiu'il noii-iiillii'r- niiditioii was romlilv III our iiisi' lilt' i]|»'nin:: \\a> iil^u at. or near, tlie ami iiisli'ail of siiiail 'lowi'l I'assinj; into 111! illli'd scliiiliilini' line, it the tivary liad for >oiiii' rrasoii oinipioi! t spai'C latiT liad ifoiio on to tiiiiioi' iIc\('1o|iiiil'1ii. It is jii-t |io"il»|.' tliat Ihi- woaUiu— in the wall liad licioini' par- ticuiarlv arci'iitiialcd clnrinL' a pn^'iiancy and that tin' ovary dnrini: it- ascent with thi' piv-naiit iiltMii- had droppi'il into thf 'aNily. Ill .Hiiclii-iuii. 1 vvi-li til lli^MiU 1)1. Kivd l!;n lor lii- ki'i.l- 111-- ill I'l'irrtill^' mil lln' IrOTrllc r- In tllr mlicli'- Iiil4 •/ nil' ill till- iiri'iiiiniti I tlii- \i.\\'fr. ni.l I mil i-pi'ri.illy ii,ili-l)li',| In Mr. Max Iti.Mlrl :iii.l lln' 1-i.iiii.hiI imi of Art ill .Mriliiilli' of till" .lollll- llo|.l^ill- Mr.lii.ll ^illool for llir r\r, 1- li'iii illii-ti iitioii-.