Cyst

“ Speaking of the aspirator, he says that cases always do so well if tapped early enough with the simple trocar and canula that aspiration is not required. The gradual expansion of the lung as the cyst is emptied is sufficient to expel all the fluid, especially if aided by the effects of coughing. In exceptional cases of old standing, where there is a thick adventitious external wall to the cyst, which is generally closely adherent to the ribs, or again in cysts of the pleura, a free antecedent incision of the external tissues is sometimes required. ”

“ Condition.—The cyst is formed in the duct, the gland itself being affected rarely. It contains a thin sticky mucus. If the cyst arises in the gland, the swelling is more deeply situated. These cysts may be attacked with an acute inflammation and finally pus is formed in them, and a very painful abscess is the result,
Symptoms.—There are no symptoms except from the size of the swelling unless an abscess occurs. Then there is an acute local pain, quite tender on pressure, and often high fever. ”

“ It is called the intra-ligamentous cyst, and needs careful and tedious enucleation for its removal. Sometimes, indeed, extirpation is out of the question, and the cyst has to be treated by the drainage-tube, as will hereafter be shown.
The contents of ovarian cysts vary very greatly in color and in consistency. In monocysts the fluid is often limpid and colorless. In multiple cysts the contents are usually syrupy, thick, and turbid. Sometimes the [p. 302] color is quite dark, as much so as weak coffee. ”

“ A strong forceps with a firm grip is needed, and one of the best is Nélaton's. While the cyst is being withdrawn the bowels are sheltered from the air and the spray by one large flat sponge, and the abdominal cavity must also be packed with smaller ones at every exposed point; and one of them should always be placed between the womb and the bladder.
In the majority of cases there is not much difficulty in freeing the cyst from its ordinary attachments and in reaching its pedicle. But should adhesions bind the cyst to the adjacent viscera, matters will not go on so smoothly. ”

“ In young cysts they occur in direct contact with the lung, but as they grow larger a thicker investment is formed, and large old cysts which have generally undergone spontaneous rupture often have a dense leathery sac. Walsh asserts that the parent cyst lies in direct contact with the lung-tissue, and, unlike that of the liver, is rarely surrounded with a thick shell or cyst-wall of pseudo-areolar tissue. ”

“ Often they create pain out of all proportion to their size. Occasionally, they break and empty their contents through fistulous communications with the intestines, bladder, or the abdominal wall. But collapse of the usually thick walls of the cyst does not take place, and a cure results far less frequently than in pelvic abscesses, which empty themselves through analogous channels. The cyst ordinarily does not lessen in size; suppuration goes on with hectic fever and exhaustion, which finally carry off the patient. ”

“ As a cyst develops it is very likely to contract adhesions to the organs with which it lies in contact. The most common adhesion is that of the omentum. Next to this is adhesion to the abdominal walls. Then will happen more rarely adhesions to the bowels, womb, bladder, pelvis, liver, and stomach. A loop of intestine will sometimes be found fastened to the front wall of the cyst, but usually the bowels lie packed behind the tumor. ”

“ The fluid is generally glairy, sometimes thick and gelatinous, often turbid and dark coloured. Not unfrequently the main cyst is subdivided, either by membranous septa, or by an aggregation of smaller cysts of the nature of hydatids. The swelling is at first on one side, and gradually rises out of the pelvis; often it remains long moveable; it increases, becomes more fixed, and ultimately fills the abdomen, displacing the viscera, and giving rise to feelings of much uneasiness, deformity, and loss of health. ”

“ Unless the cyst be papillomatous, the bland, unirritating fluid is readily absorbed by the peritoneum, and the cyst may remain quiescent for a long period.
Cysts of the parovarium occur most frequently during the period of active sexual life. Unlike dermoids and cysts of the oöphoron, they are unknown in childhood.
Cysts of the parovarium are much less common than cysts of the oöphoron and paroöphoron. In 284 tumors of the ovary and parovarium operated upon by Olshausen, about 11 per cent. originated in the parovarium. ”

“ As a result of injury the cyst may undergo sudden enlargement from hæmorrhage into its interior.
Recurrent attacks of inflammation frequently occur, especially in wens of the face and scalp. Suppuration may ensue and be followed by cure of the cyst, or an offensive fungating ulcer forms which may be mistaken for epithelioma. True cancerous transformation is rare. ”

“ In addition to this a cystic or resting stage occurs, when conditions under which the parasite exists become adverse.
A sexual process, called autogamy, occurring within the cyst wall was described by Schaudinn, though recent authorities are inclined to doubt it. The process, as described, is as follows: The cyst contains at first but one nucleus, which divides into two. Each nucleus is then said to break up into chromidia and disappear, but to reappear later as a smaller and less distinct secondary nucleus on each side of the cell. Each secondary nucleus again divides into three ”

“ I dissected a cyst as perfectly as possible, and placed them in spirits; at the same time regretting that I had no means of preserving the joint with the cyst attached entire. Similar worms are said to exist in the stomach and intestines of the animal. These cysts, I understand, are not uncommon; some persons have asserted that they have never killed a kangaroo without them, whilst others declare they are more common in males than in females, [113] and are found in two kangaroos out of three. ”

“ Power, surgeon, at Bosworth in Leicestershire, on examining the body of an elderly lady who died of this disease, March 29, 1793. "On opening the abdomen I found a large cyst attached to the left ovarium by an elastic neck as thick as the little finger, and so callous as not to admit of being separated by scissars without considerable difficulty. The substance of the cyst had an appearance much resembling the gravid uterus near the full period of gestation, and was as thick. It had no attachment to the peritonæum, or any of the viscera, except by the hard callous neck I have mentioned ”

“ A hydatid cyst may be situated upon any part of the kidney. If small, it may never make its presence known. A larger one may give rise to those vague pains in the back found with so many diseases of the kidney and characteristic of none of them. A cyst may open in any direction, but is more likely to empty into the pelvis of the kidney. When this happens, the smaller cysts or pieces of the larger ones often enter the ureter and give rise to renal colic, and possibly, later, to a pyelitis. Other points of discharge are the intestines, the lungs, or the abdominal walls. ”

“ Six months later the patient had recurrence of pain in the same tooth of two months’ duration; it was extracted and pus continued to exude from the socket. A probe, passed 21⁄2 centimeters to the floor of the nose and septum, showed a cavity covered with membrane in the anterior parts of upper jaw, which was a cyst at the root of the tooth. The anterior cyst walls were removed with bone forceps, and the remainder scraped. The cavity gradually healed.
The cyst probably broke through under the septal mucous membrane. ”

“ Encystment, or at least a resting stage at full growth, is very characteristic, and frequently an excretion of granules takes place into the first-formed cyst, whereupon a second inner cyst is formed which may be followed by a third. These brood-cysts, in which multiple fission takes place, may be of two kinds, ordinary and resting, the latter being distinguished by a firm, and usually ornamented and cuticularized cell-wall, and only producing its zoo spores after an interval. ”

“ The cystic lymphangioma, lymphatic cyst, or congenital cystic hygroma is most often met with in the neck—hydrocele of the neck; it is situated beneath the deep fascia, and projects either in front of or behind the sterno-mastoid muscle. It may attain a large size, the overlying skin and cyst wall may be so thin as to be translucent, and it has been known to cause serious impairment of respiration through pressing on the trachea. In the axilla also the cystic tumour may attain a considerable size (Fig. 76) ”

“ Sometimes the cyst becomes infected and suppurates, and finally ruptures on the surface. This may lead to a natural cure, or a persistent sinus may form. Dermoids more deeply placed, such as those within the thorax, or those situated between the rectum and sacrum, give rise to difficulty in diagnosis, even with the help of the X-rays, and their nature is seldom recognised until the escape of the contents—particularly hairs—supplies the clue. The literature of dermoid cysts is full of accounts of puzzling tumours met with in all sorts of situations. ”

“ Subsequently the peritoneum was found dotted over with minute nodules furnished with tufts of hair growing among the visceral adhesions. When a woman with an ovarian cyst contracts typhoid fever, the cyst may become filled with pus which contains the bacillus typhosus. Such a case occurred in my practice in 1907.
For many years I have abandoned the use of clumsy trocars of all kinds and remove the tumour entire, although it may require an incision from the ensiform cartilage to the pubes. These large incisions heal quickly, and are no more prone to hernia than the short incisions. ”

“ Such cysts are generally of small size, and pyriform shape; externally they are smooth, membranous, and of rather a delicate texture; internally, they are lined by lymph of soft consistence, and contain purulent matter. In fact, they are purulent depôts, which form in consequence of inflammation around the fangs of the teeth, and from which the matter is occasionally discharged through a small aperture at the upper part of the cyst, and by the side of the affected tooth. They sometimes attain a very considerable size. ”

“ The only remedy is to open the enlarged part from end to end, carefully to take out the gossamer lining of the cyst, and then to insert some bits of lint on each side of the incision, in order to prevent its closing too soon. In a few days, the parietes of the cyst will begin to adhere, and a perfect cure will be accomplished
If the tumour is simply punctured, the incision will speedily close, and the cyst will fill again in the space of four-and-twenty hours. ”

“ 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 cyst-wall 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 portion of the ovary that contains the cysts may be excised and the wound in the ovary closed by sutures of fine catgut. Simple puncture of the cysts does no good. The conservative operation is especially desirable in case both ovaries are diseased. ”

“ With the hand in the rectum the cystic ovary is pressed against the wall of the pelvis or abdomen, until the attenuated wall of the cyst gives way, the fluid is left in the abdominal cavity, to be absorbed and many animals will afterward become pregnant. In a large proportion of cases in which the symptoms are marked, the walls of the cyst are sufficiently attenuated to allow of rupture by pressure, and, if the escaping contents are free from infecting microbes, no immediate harm comes to the peritoneum. ”

“ Sometimes unhealthy abscess occurs, with thickening, infiltration, and condensation of the surrounding cellular tissue; in such cases, incision and poultice are required, and occasionally it is necessary to destroy the unsound cellular tissue and the degenerated cyst by free application of the caustic potass. The cyst is thus got rid of, healthy granulation takes place, and by afterwards avoiding undue pressure upon the part, a permanent cure is obtained. ”

“ The glandular cyst, however, is of rapid, continuous, unlimited growth, and usually destroys the woman within a period of three years. Life has been prolonged for a much longer period in some cases by palliative treatment and tapping. On the other hand, life may at any time be cut short by the occurrence of some accident, such as rupture or torsion of the pedicle.
Symptoms of the Accidents that occur in Ovarian Cysts.—The symptoms of inflammation are pain and tenderness over the surface of the tumor. ”

“ The former of these consists, at one stage of its existence, of a small globular mass of protoplasm, from the whole periphery of which a multitude of fine pseudopodia radiate. When about to reproduce, the creature retracts its pseudopodia, and forms around its exterior a structureless coat or cyst, an action which takes place frequently in lowly organisms, and is called their process of encystment. The contents of the cyst then divides into separate bodies, which escape by the rupture of the cyst. ”

“ Infection in man occurs by way of the mouth by the ingestion of cysts. A patient showing acute symptoms of dysentery is not usually infective, for he is merely harbouring the large trophozoites, which, by experiment, have been shown not to be infective to animals (kittens) when administered by the mouth. The stools of recovered patients may still contain cysts, and they may thus act as cyst-carriers or reservoirs of disease by infecting water and soil. The stools of such cyst-carriers are often solid, and so cysts of E. histolytica (tetragena) are easily overlooked. ”