Gynecological pathology; a manual of microscopic technique and diagnosis in gynecological practice, for students and physicians

Front matter

Class Book if^

Copyright ]<^

COPyRIGHT DEPOSIT.

Preface To The Second Edition

Since the appearance of the valuable investigations of Ruge and Veit, the microscopical examination of tissue excised and curetted from the uterus has become a necessary adjunct to gynecological diagnosis, so far as such diagnosis is concerned with affections of the uterus. The necessity of this method of diagnosis has been called to the attention of physicians by the numerous works on this subject. It is therefore natural that a much larger percentage, not only of specialists, but also of general practitioners, should seek knowledge of this subject. The numerous individual works scattered in various journals and archives make its study a question of time and patience. These works, which follow one or another of the numerous questions into minute details, are in nowise calculated to interest a beginner. In the large text books this branch of gynecology has received attention, but much that is important is dismissed with a few words. To overcome these difficulties is the purpose of this book, which is intended to serve as an introduction to practical experience.

Due weight is given to the consideration of normal conditions, for a knowledge of these is necessary before one can appreciate pathological changes. This is especially true of the uterus, since its structure is normally subject to many variations.

References to the literature are made only where necessary. The drawings, which with few exceptions are taken from my specimens, have been taken directly from the true microscopical picture, and schematic drawings have been avoided, since the latter are not suitable for practical instruction.

The second edition has been considerably enlarged, especially the chapters on the vulva, vagina, tubes, and ovaries. Although not treated generally in extenso, I have given what my experience has proved to be absolutely necessary and of practical gynecological value.

Carl Abel.

Berlin, July, 1899.

Preface To The Translation

In spite of the glowing results obtained in operations for carcinoma of the cervix and uterus, so far as immediate mortality goes, only a small percentage fail to suffer from a recurrence of this malignant growth. In no branch of medicine, therefore, is an early diagnosis so necessary. Since the great majority of patients see their physician before consulting a gynecologist, the onus of making a correct diagnosis rests with him, and it is his duty to make a test excision from the cervix, or a test curettage of the uterus in all cases where the possibility of the presence of a malignant growth is suspected. Aside from this the various forms of endometritis, polypus, sarcoma, etc., can be diagnosed only by microscopical examination, and early malignant changes can be recognized. Then again the differential diagnosis between abortion and extrauterine gestation is all-important and may frequently be made by microscopical examination of expelled particles. The value of a microscopical diagnosis is also evident in the case of tuberculosis or gonorrhea of the genitalia. Having been associated for a long period with Dr. Abel in his pathological work, I realize that this book meets most fully the demands not only of the specialist, but also of the beginner, for it is the result of clinical experience and is intended for practical purposes only. In translating this book, I feel that a most valuable addition is made to our at present meagre diagnostic repertory, and that the adoption of methods here described will be the means of saving many a life. The chapter on embryology and on the origin of growths from embryonal cells and organs has been added by me as an aid to the understanding of what is, perhaps, the most interesting part of pathology. In no other portion of the body are these processes more complex and in no other area is the theory of Cohnheim so well exemplified.

Samuel Wyllis Bandler.

New York, November, 1901.

Part I. — Technique. PAGE

I. Material ' 1

1. Obtaining the Material 2

(a) Test Excision from the Portio Vaginalis 3

(ft) Test Curettage of the Endometrium. 4

(c) Test Excision from the Vagina and External Genitalia. . 4

II. Further Treatment of the Material Obtained 5

1. Examination of Fresh Specimens 5

2. Fixing the Specimens 8

(a) Muller's Solution 8

(&) Saturated Watery Solution of Corrosive Sublimate.... 8

(c) Zenker's Fluid 8

( d ) Fleming's Solution 8

3. Hardening and Embedding the Specimens 8

(a) Glycerin-Gelatin for Fastening the Specimen 9

(&) Cutting Alcohol Specimens with the Freezing Microtome 10

(c) The Embedding of Specimens in Celloidin 10

(d) The Embedding of Specimens in Paraffin 11

4. Cutting Hardened Embedded Specimens with a Microtome 12

5. Staining the Sections 13

(a) Picrolithiocarmin 13

( & ) Hematoxylin 14

(c) Staining of Elastic Fibres. 15

1. Taenzer's Orcein Stain 15

2. Weigert's Fuchsin-Resorcin Stain 15

6. Staining of Micro-organisms 16

(a) The Gonococcus 16

(a) Dry Cover-Glass Specimens 16

(/3) Cut Sections 17

( 6 ) Tubercle Bacillus 17

(a) Dry Cover-Glass Specimens 17

ifj ) Cut Sections 18

III. The Management of Material Obtained by Laparotomy or Autopsy 18

1. 70 Per Cent. Alcohol 18

2. Muller's Fluid 18

3. Formalin 19

IV. Appendix to Part I. — Instrumentarium 20

Part II. — Diagnosis

I. Vulva 22

(a) Inflammations 23

(6) Ulcerations 23

Vlll CONTENTS.

PAGE

(c) Atrophies 23

(d) Hypertrophies 24

(a) Epithelial 24

( /3) Connective Tissue 25

( e ) Neoplasms 25

(a) Epithelial 25

(|3) Connective Tissue 26

II. Vagina 26

(a) Inflammations 27

(&) Ulcerations 27

( c) Hypertrophies 27

(d) Neoplasms 27

(a) Epithelial 27

( /3 ) Connective Tissue 28

(e) Cysts 28

III. The Neck of the Uterus (Cervix Uteri) 28

(a) In Sections through the Squamous Epithelium 33

(&) In Sections through Glands Lined with Cylindrical

Epithelium 35

A, Inflammations ' 39

(a) bimple Inflammation of the Vaginal Portion 39

( b ) Ulcers of the Vaginal Portion 40

(c) Ectropion and Inflammation of the Cervical Mucous

Membrane 42

(d) Erosions 45

B. Neoplasms 49

1. Hypertrophy of the Outer Surface of the Vaginal Portion. . . 49 (a) Hypertrophy of the Epithelium 49

( a ) In Prolapse 49

( (3 ) Condylomata Acuminata 50

(&) Hypertrophy of the Stroma 51

( a ) Elongation of the Cervix 52

( (3 ) Cervical Polypi 52

3. Malignant Adenoma of the Cervix 66

4. Sarcoma of the Cervix 66

5. Myoma, Fibroma, Fibromyoma 68

6. Tuberculosis of the Cervix 68

IV. The Body of the Uterus 69

A. The Mucous Membrane of the Uterus (Endometrium) 70

(a) The Endometrium of the Female after Puberty, in a

State of Rest 70

(6) The Endometrium during Menstruation 74

(c) The Endometrium during the First Months of Intrauterine Pregnancy 78

CONTENTS. IX

PAGE

(d) The Endometrium in Extrauterine Pregnancy 82

(e) Differential Diagnosis between Menstrual Decidua,

Uterine Decidua in Intrauterine Pregnancy (Abortion) , and Extrauterine Gestation 85

A. General Remarks 89

B. Inflammation 92

(a) Interstitial Endometritis 92

(6) Hypertrophic Endometritis (Fungosa) 94

(c) Decidual Endometritis 97

C. Hyperplasia 97

(a) Hyperplasia of the Entire Endometrium 97

(a) Diffuse 97

) /3 ) Circumscribed (Polypoid) 97

(&) Glandular Hyperplasia of the Endometrium 99

(a) Diffuse 99

(/? ) Circumscribed (Polypoid) 100

D. Neoplasms 100

(a) Carcinoma of the Endometrium 100

(&) Malignant Adenoma of the Endometrium 102

(c) Sarcoma of the Endometrium 104

( a ) Sarcoma of the Mucous Membrane 104

( [3 ) Sarcoma of the Uterine Wall 104

(d) Destructive Neoplasms Arising in Connection with

Pregnancy 105

(a) Deciduoma •. 105

ij3) Chorioma (Waldeyer) 106

(e) Tuberculosis of the Endometrium 108

B. The Wall of the Corpus Uteri (Myometrium) 108

1. Inflammations 108

Myoma, Fibroma 109

V. The Tubes 110

(a) Position and Course 110

(6) Classification of Various Sections of the Tube 110

(c) Changes Occurring within Normal Limits 114

( ) Menstruation 114

( /'? ) Senile Changes 115

( y ) Changes in Pregnancy 115

A. Malformations 115

( a) Infantile Tubes 115

(&) Accessory Tubes and Tubal Ostia 115

(c) Hernial Dilatations (Diverticula) of the Tubal Canal.. 116

(d) Pedunculated or Morgagni's Hydatids 116

B. Tubal Gestation 116

(a) Causes 116

(&) Places of Insertion of the Ovum in the Tube. 117

(c) Changes in the Tubal Lining in the Region of the Ovum

in Tubal Gestation 118

(a) Basal Decidua of the Tube (Serotina) 118

S CONTENTS.

PAGE

(/?) Decidua Vera of the Tube 119

iy) Capsular Decidua of the Tube (Reflexa) 120

id) The Tubal Wall in the Region of the Fetal Sac 120

(e) Chorionic Villi 120

if) The Portion of the Tube at a Distance from the Fetal Sac,

and the Tube of the other Side 121

(g) The Results of Tubal Gestation 121

C. Disturbances of Circulation 122

Hematosalpinx 123

D. Inflammation 124

(a) General Remarks 124

(&) Catarrhal Salpingitis 125

( c) Purulent Salpingitis 127

(d) Tubo-Ovarian Tumors 134

E. Infectious Granuloma 137

F. Hypertrophies and Hyperplasias 137

G. Neoplasms 138

VI. Ovaries 139

A. Position and External Form 139

B. Anatomical Structure 140

(a) The Vascular Layer 140

(&) The Parenchymatous Layer 141

( a ) The Stroma 141

( ,3 ) The Follicle 141

1. Follicles in a State of Rest 142

2. The Graafian Follicle 142

(c) Further Course of the Ripe Follicle 142

( a) Corpus Luteum 143

( /3 ) Corpus Albicans \ 144

C. The Ovary during Menstruation and Pregnancy 145

D. Senile Atrophy of the Ovary 145

A. Ovarian Gestation 145

B. Disturbances of Circulation, Hyperemia 146

C. Inflammation 146

(a) Interstitial Oophoritis 147

( & ) Perioophoritis 147

D. Infectious Granuloma 148

E. Parasites ; 148

F. Microcystic Degeneration 148

G. Neoplasms 149

1. Epithelial Neoplasms 150

( a) Surfa.ce Papilloma 150

( (3 ) Follicle Cysts 150

(y) Corpus-Luteum Cysts 150

( z/) Cystomata or Cystadenomata of the Ovary 153

(a) Simple Cystadenoma 153

(&) Papillary Cystadenoma (Proliferating) 154

( E ) Carcinoma of the Ovary 157

2. Connective-Tissue Neoplasms 158

(a) Fibroma 158

CONTENTS. XI

PAGE

(y) Sarcoma 159

3. Dermoid Cysts 159

VII. The Parovarium 160

2. Parovarian Tumors 160

Part III. — Embryology of the Female Genitalia and the Pathological Growths Developing from Embryonal Structures

Embryonal Vesicle 164

Caudal Intestine 166

Pronephros 167

Mesonephros, or Wolffian Body 167

Wolffian Ducts 170

Ureter . 172

Ducts of Miiller 174

Cloacal Membrane and External Genitalia 175

Vagina 178

Kidney 179

Ovary 180

Duct of Gartner 181

Parovarium 182

(a) Epoophoron 182

( h ) Paroophoron 182

Testicle 184

Parovarian Rests 185

I. Growths Originating from the Epoophoron 185

( a ) Small Parovarian Cysts 186

( i3) Large Parovarian Cysts 186

(y) Adenomata and Fibroadenomata of the Epoophoron 187

( z/ ) Mesonephritic Adenomata of the Ovary 187

( t- ) Mesonephritic Cystomata of the Ovary (Ovarian Cysts).... 188

(a) Simple Serous Cystoma 188

(&) Papillary Serous Cystadenoma 188

(c) Glandular or Papillary Pseudomucinous Cystadenoma.. 188

id) Surface Papilloma 189

(e) Grape-like Cysts 189

II. Growths Resulting from the Paroophoron and from Displaced Rests of

the Wolffian Body ' 189

Displacement of Wolffian Body Cells 191

( a) Fibroadenoma of the Ligamentum Teres 191

(j3) Paroophoral Cysts of the Broad Ligament 192

( X ) Cystomyomata of the Broad Ligament 192

( z/ ) Adenomata and Fibromata of the Cervix 193

( 6 ) Adenomata and Cystadenomata of the Posterior Abdominal

Wall 193

( C ) Glands and Cysts of the Myometrium 193

(. 77) Subserous Glands of the Uterus 193

Xll CONTENTS.

PAGE

( 5 ) Retrouterine Subperitoneal Cystomata 194

(z ) Adenomata of the Tubal Angles 195

( K ) Adenomyomata of the Uterus and Tubal Angles. . . , 195

Adenomata of the Uterus and Tubal Corners Originating from the

Mucosa 199

Adenomyomata of the Uterus and Tubal Corners Originating from the

Mucosa 200

Doubtful Cases 200

Salpingitis Nodosa Isthmica 201

Cytogenic Tissue 202

III. Duct of Gartner and Growths Originating From It 203

( a) Cysts of the Duct of Gartner in the Parametrium 205

{ft) Cervical Cysts of the Duct of Gartner 205

{y) Adenomata and Adenocystom.ata of the Duct of Gartner.,.. 206 (A) Adenomatous Hyperplasia of the Cervical Gland Appendage. 206

Vaginal Cysts 206

{a) Cysts in the Lateral Wall 208

{ft) Cysts in the Posterior Wall 208

{y) Cysts on the Anterior Vaginal Wall 209

{A) Cysts Scattered over More than One Wall 209

Cysts of the Labium Minus 210 fV. Tumors Resulting from Cells Displaced by the Wolffian Body and

( oi) Mixed Tumors of the Kidney 214

{ft) Retroperitoneal Dermoid Cysts 215

{y) Mixed Tumors and Dermoid Cysts of the Ovary 216

{A) Mixed Tumors of the Vagina and Cervix Uteri 220

{ £) Dermoid Cysts of the Cervix 221

( C) Dermoid Cysts of the Pelvic Connective Tissue 221

{rj ) Dermoid Cysts of the Uterus 222

LIST OF ILLUSTRATIONS.

FIG. PAGE

1. Self-Retaining Speculum 2

la. Edebohls' Speculum 3

2. Transferring tlie Section to the Slide 6

3. Glass Cylinder for Preserving the Specimen to be Examined 9

4. Longitudinal Section through a Uterus 29

5. Vaginal Surface of the Cervix Uteri 30

6. Transition of the Squamous Epithelium of the Portio Vaginalis to

Cylindrical Epithelium of the Cervical Lining 31

7. Cervical Mucous Membrane 82

8. Section through a Pointed Condyloma 34

9. Longitudinal Section through a Gland lined with Cylindrical

Epithelium 35

10. Transverse Section through a Cylindrical Cell 35

11. Oblique Section through a Gland 35

12. Section through the Fundus of a Gland 3&

13. Decubitus Ulcer of the Vaginal Portion in Total Prolapse of the Uterus 41

14. Test Excision from the Vaginal Portion after Much Cauterization —

Benign Growth of Epithelium 44

15. A So-called "Erosion" of the Vaginal Portion 46

16. Polyp of the Cervix (Originating from the Vaginal Surface) 53

16a. Cervical Polyp (Originating from the Mucous Membrane of the Cervix) 54

17. Cervical Polyp with Cysts 55

18. Carcinoma in a Vein 58

19. Cells of a Carcinomatous Alveolus with So-called Protozoal Contents. . 61

20. Cancer Alveolus More Highly Magnified (Fixed in Bichloride) 62

21. Carcinoma of the Vaginal Portion (Highly Magnified) 63

22. Carcinoma of the Cervix (General View) 64

23. Gland whose Wall at one side is Destroyed by Carcinomatous Changes 65

24. Tuberculosis of the Cervix 69

25. Almost Normal Endometrium (Slight Increase in the Glands) in its

Relation to the Muscularis (Low Power) 71

26. Almost Normal Endometrium (High Power-) 72

27. Decidua of Menstruation : 77

28. Decidua in intrauterine Pregnancy (Abortion) at the Second Month

of Pregnancy 80

29. Spontaneously Expelled Uterine Decidua in a Tubal Gestation 84

30. Expelled Piece of Tissue in an Abortion 86

31. Chorionic Villi (High Power) 87

31a. Section through a Blood Clot removed from a Uterus after Abortion

(T^ow Power) 88

XIV LIST OF ILLUSTRATIONS.

FIG. PAGE

32. Interstitial Endometritis 93

33. Hypertrophic Endometritis (Fungosa) 95

34. Hypertrophic Endometritis with Bleeding into the Glands 96

35. Circumscribed Hyperplasia of the Whole Endometrium (Polypoid) ... 98

36. Prom the Polyp "a," Fig. 35, Strongly Magnified 99

37. Carcinoma of the Endometrium 101

38. Interstitial Portion of the Tube Ill

39. Isthmus of the Tube (Near the Ampulla) .^^-^ 112

40. Fimbriated End of the Tube , rvC 113

41. Change of the Tubal Mucous Membrane to Decidua 118

42. Section through the Area of Insertion of the Ovum in a Gravid Tube. . 121

43. Fimbria with Hyperemia and Lymphatic Congestion 123

44. Swollen Fold of Tubal Mucosa with Decided Round-Celled Infiltration. 126

45. Chronic Salpingitis 128

46. Chronic Purulent Salpingitis 129

47. Chronic Purulent Salpingitis (Hyperplastic) 130

48. Chronic Purulent Salpingitis 131

49. Chronic Purulent Salpingitis with. Atrophy of the Folds (Atrophic) . . 132

50. Chronic Purulent Salpingitis (Tube Wall) 133

51. Tubal Abscess 134

52. Adhesion between Tube and Ovary (Macroscopical) : 135

53. Tubo-ovarian Tumor 135

54. Tubo-ovarian Tumor (Low Power) 136

55. Carcinoma of the Tube 138

56. Parenchymatous Layer of the Ovary 141

57. Graafian Follicle 143

58. From the Wall of a Corpus Luteum 144

59. Enormous Hypertrophy of the Blood Vessels in an Ovary in a Case

of Myoma of the Uterus 146

60. Interstitial Oophoritis 147

61. Microcystic Degeneration of the Ovary 149

62. Corpus-Luteum Cyst (Enlarged Three Times) : 151

63. From the Wall of a Corpus-Luteum Cyst (High Power) 152

64. Simple Cystadenoma of the Ovary 154

65. Proliferating Glandular Colloid Cystadenoma (Moderate Magnification) 155

66. Proliferating Glandular Colloid Cystadenoma (High Power) 156

67. Carcinoma of the Ovary 157

68. Glandular Carcinomatous Cystadenoma. 158

69. Section through the Wall of a Dermoid Cyst of the Ovary (Moderately

Magnified) 160

70. From the Wall of a Dermoid Cyst (High Power) 161

71 Teratoma of the Ovary (Macroscopical) 162

Part III.

72. Caudal End of Embryonal Vesicle 164

73. Middle Blastodermic Layer of Human Embryo 165

74. Schematic Development of Animal and Vegetative Canals 165

75. Human Embryo 2.4 mm. Long 166

76. Caudal End of Human Embryo of 3 mm 166

77. Pronephros of Ichthyophis Gut, in Transverse Section 167

78. Rabbit Embryo of 8 Days and 21 Hours — Transverse Section 167

79. Rabbit Embryo of 8 Days and 23 Hours — Transverse Section 168

80. Human Embryo of 5 mm. — Transverse Section 168

LIST OF ILLUSTRATIONS. XV

FIG. PAGE

81. Wolffian Body Tubules— Human Embryo of 10.2 mm 169

82. Human Embryo of 5 mm. — Sagittal Section 169

83. Transverse Section of Rabbit Embryo, Showing Wolffian Duct 170

84. Transverse Section through Guinea-pig Embryo 170

85. Caudal End of Human Embryo of 4.2 mm 171

86. Caudal End of Human Embryo of 6.5 mm 171

S7. Pelvic End, Human Embryo of 11.5 mm. (4i/^ weeks) 172

88. Pelvic End, Human Embryo of 14 mm 173

89. Transverse Section, Upper End of Wolffian Body of Embryo of 12 mm. 174

90. Pelvic End, Human Embryo of 29 mm 175

91. Transverse Section, Human Embryo of 9 Weeks, at Level of the

Bladder 176

92. Genital Strand, Human Embryo of 9 Weeks 176

93. Schematic Arrangement of Internal Genitalia, Human Female Embryo

94 and 94rt. Ducts of Muller and Wolff, etc., of Fig. 90, Magnified 178

95. Human Embryo in the Fifth Week 179

96. Section through Ovary of Human Embryo of 11 cm 180

97. Wolffian Body and Ovary of Human Embryo of 17 mm 181

98. Tube, Uterus, and Ovary at Beginning of Third Month 182

99. Wolffian Duct and Duct of Muller 183

100 Human Embryo of 4.5 mm. (Third Week) — Transverse Section at

Level of Arm Formation 213