Papillary growths of the ovary are of three kinds—the true ovarian papilloma, the colloid papillary cystoma, and the papillary cystocarcinoma. A case of endothelioma also met with, taking the form of papillary excrescences in an ovarian cyst. The ovarian papillomata resemble each other in their naked-eye characters, in the formation of excres cences on the outer surface of the cyst wall, in their implantation on the peri toneum, and in the concomitant exist ence of ascites; further, troth are fre quently bilateral and intraligamentary in nature. But the ovarian papilloma is to be distinguished by the following characters: it is quite benign; its epi thelial proliferation never invades sur rounding tissues in a destructive way; it grows slowly and does not occa-ion cachexia; and it does not cause metastatic growths. Generally papil Ionia retains its benign character, even when it has existed for several years. On the other hand, the papillary cysto carcinoma is from the beginning a true carcinoma, and not a papilloma with can cerous degeneration. The ovarian papil loma most often originates in the sur face epithelium of the ovary. When ex tirpated, such a growth does not return; but the other ovary, even if apparently healthy, ought always to be removed also, for it will ultimately develop simi lar tumors. Oscar Semb (Sapp. Norsk Mag. f. Laegevid., Oct., 'M).
Dermoid tumors are recognized by their irregular consistency, in some places soft and in others hard. The recogni- .
tion that the tumor has been in ence for ten years or more will indicate a probable dermoid. Olshausen entiates parovarian growths by moder ate size, slow growth, thin, relaxed walls, light fluid contents, and very dis tinct fluctuation. Large cysts are gen erally multilocular.
Double intraligamentary growths and the presence of ascites with small tumors is a presumption of papillary growths, but not a positive indication. Super ficial papillomata feel firm, nodular, and often extend diffusely into the pelvis. A rapid-developing ascites in which re nal, cardiac, and hepatic causes can be excluded, should, in the presence of bi lateral resistance, awaken a suspicion of ruptured papillary ovarian cyst. Pro nounced solid consistence of a growth is common to ovarian fibroid, sarcoma, en dothelioma, carcinoma, and teratoma. An ascitic accumulation as a compli cation is a presumption of malignant trouble. Pronounced cachexia and ma rasmus may be produced by certain com plications, as rupture, torsion, inflam mation, also in tumors of normal size. Rapid growth especially speaks for ma lignancy. Olshausen directs attention to premature oedema of the legs as a symp tom of cancer.
Etiology.—Various theories have been advanced as a cause for the development of ovarian tumors. Cohnheim believed them to originate from retained embry onic products. It was formerly supposed that the dermoid was thus derived, hut the diversity of structure found in the dermoid, and especially in the teratoma, precludes the possibility of such origin and favors the assertion that they arise from ovum-cells which have been sub jected to some special irritation. The variety of irritation, whether mechanical or chemical, animate or inanimate, dif fers in various kinds of tumors is as yet unknown. It is probable that it is chem
ical irritation which has proceeded by way of the uterus and tubes. Suscepti bility for the acceptance of the tumor exciters varies in different individuals. in which the heredity, acquired disposi tion, age, trauma, scar-formation, and inflammation are important factors. Age has no special significance, though gland ular cysts are more frequent between the thirtieth and fiftieth years. All varieties are less frequent in childhood and old age. Ovarian growths are more frequent in the single than in the married.
Course.—Proliferating cysts grow more rapidly than either the dermoid or solid tumors unless the latter are malignant. A rapid increase in the size of a growth noticeable from day to day is due to hemorrhage. When the pelvic structures are normal, an enlarged cystic ovary will drop by its weight into Douglas's pouch. As it increases in size, it advances in the direction of least resistance, which is up ward, and pushes before it the intestines, when it will rise out of the pelvis and impinge against the abdominal wall. It then assumes a central position. The tumor lies directly above the uterus, rests on the brim of the pelvis, and causes but little inconvenience. Occasionally it may become impacted, because of irreg ularities in its growth or from extensive adhesions. The tumor rests upon the pelvis; as it advances it pushes the in testines upward and laterally. If undis turbed, the enlargement becomes so great that the diaphragm is pushed up ward, severe pressure symptoms follow, and the action of the heart and lungs is obstructed. Marked suffering, emacia tion, and the development of the charac teristic facial expression known as facies ovariana follow. The presence of ova rian tumors does not interfere with ovu lation and menstruation, even though both ovaries arc involved, so long as ova rian stroma remains. Thornton reports a case of pregnancy with bilateral der maid disease.
Complications.—Among the complica tions or ovarian tumors, ascitcs occurs in frequently with cystic growths, unless from rupture, but is very frequent in the solid. The cause is unknown; it may possibly arise from pressure upon the versa cava or large veins. The oedema may enlarge one or both legs. The ureter and pelvis of the kidney may be dilated.
The Most frequent complication is the formation of adhesions between the sur face of the tumor, the omentum, the in testines, the uterus, the bladder, and the abdominal wall. These adhesions arise from inflammation, as in peritonitis. When not associated with inflammation they arise from loss of epithelium from the surface of the cyst, through friction. Adhesions may become dense, firm, often thread-like, and may convey large ves sels between the omentum and growth. Adhesions are frequent in dermoid growths. When adhesions exist between the tumor and bladder, an opening may occur through which its contents are evacuated; openings also occur between the tumor and bowel. Adhesions are of importance because of the increased dif ficulty in the removal of the growth.