of Rhodes. Spurious works Andronicus.

The American journal of obstetrics and diseases of women and children online

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"Folliculum Malignum Ovarii," Table X, Fig. 4. Formation of solid ground
bodies and central cystic degeneration.

lar round or oval, variable-sized vesicles separated by connective
tissue. These vesicles are lined with a single layer of epithelial
cells, usually cuboid, occasionally columnar. They contain
a colloid substance which is sometimes very granular in appear-
ance and in places contains fragments of epithelial cells.



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624 proescher: teratoma strumosum thyreoideale ovarh.

Vesicle multiplication can be seen throughout the mass. All
stages of development, from a single cord of cuboid epithelial
cells to secreting vesicles, are observed, also the stages of degen-
eration of vesicle into cyst. Besides the occurrence of short cords
consisting of a single row of cuboid cells we see several parallel
rows of cells lying side by side, some of which show beginning
canalization ; they are lined by a single layer of cuboid or cylin-
drical cells. The mature vesicles may be seen undergoing de-
generation into cysts, the occurrence of a great many of these



Fig. 8. — Anspach's case. (University of Pennsylvania Medical Bulletin, 1903.)
Section through dermoid prominence. A, Primordial follicle, in ovarian stroma.
B. Struma colloides. C. Mucous glands. D. Sebaceous glands.

small cysts together gives the appearance of a multilocular
cyst. In time, the thin connective-tissue walls separating, they
gradually disappear, converting this multilocular group into a
large monolocular cyst.

Some of the reported cases show deviations from the above
description: Gottschalk's case* showed hemorrhagic areas.
Some vesicles in Glockner's cases were filled with darkly stained
colloid in which were points of calcification, and a formation
resembling a sweat-gland was seen. One of R. Meyer's cases
contained several small bone formations and a small portion

♦Gottschalk described a tumor in 1899 which he called "folliculoma maglinum;"
that tumor was a teratoma strumosum thyreoideale ovarii.



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proescher: teratoma strumosum thyreoideale ovarii. 625

of voluntary muscle tissue. Stroganowa's contained several
cysts whose walls were calcified and hard as bone, inside those
cys^s there was nothing but a yellowish necrotic mass. Lecfene's
Case I contained a salivary gland formation; Case II, in addition
to thyroid tissue, contained strands of hair, salivary gland, and
an area of carcinomatous degenerated skin. Polano's was the
smallest formation of this kind reported, it was a pyramid -shaped
formation of thyroid tissue measuring 1/2 cm. from base to
apex, and occurred in an ovary which was the size of a child's
fist ; it was sharply outlined from the ovarian tissue and showed



Fig. 9. Fig. 10.

Figs. 9 and 10. — Robert Meyer's case. Virchow's Archiv, 1903, p. 538. Micro-
photographs, showing various stages in the development of follicles containing
colloid.

plainly its dark red color outlining it from the grayish-white
ovary tissue; its base was at the periphery of the organ. The
chart will aid in comparing the reported cases.

We have observed three of these interesting tumors. Two
of them were removed in the Mercy Hospital, Pittsburg, by
Drs. Werder and Weiss, and one in the Allegheny General
Hospital by Dr. Simpson. To those gentlemen we are indebted
for the privilage of examining the tumors and for the histories
and clinical data that accompanied them.

Case I. — A woman thirty-six years old had been married for

two years and was sterile. She had always enjoyed good health

until a few months after marriage, then her menses became

irregular. Some months later they ceased, and she noticed her

4



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626 proescher: teratoma strumosum thyreoideale ovARn.

abdomen enlarging and suspected pregnancy. Three weeks
after first noticing the enlargement of her abdomen she had an



Fig. II.



Fig. 12.

Lec^ne's case. Annales de Gynaekologie et Obst. Paris, 1964.
Fig. II. — Low magnification. A. Showing thyroid tissue. B. Salivary glands.
Fig. 12. — High magnification. Showing follicles filled with colloid.

attack of peritonitis, which subsided. Six months later she was
admitted to hospital having the appearance of one eight months'
pregnant. On admission her breasts, lungs, heart, liver, and



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proescher: teratoma strumosum thyreoideale ovarii. 627

kidneys were found normal, a tumor was palpated in the lower
left portion of the abdomen, and her legs were edematous.

A laparotomy was performed and an oval tumor, covered
with adhesions and attached to the adnexa uteri of the left side
removed. Andexa of the right side normal.

Macroscopic Appearance. — The upper half of the tumor was
cystic and fluctuated, the lower half was solid. It measured
21x25x18 cm., and weighed 1,800 grams. The left ovary had
disappeared, the broad ligament was very thin and elongated,
the tube and fimbria werewell preserved.

When the capsule was incised over the upper cystic portion
500 c.c. of a thick grayish fluid flowed out. On longitudinal
section the capsule was found to vary in thickness from 2 to 5 mm.,
it was composed of dense fibrous tissue having a smooth outer



Fig. 13. Fig. 14.

R. H. Bell's cases. British Journal of Obstetrics and Gynecology, 1905.
Fig. 13. — Section under low power, from case occurring in 1902.
Fig. 14. — Small portion under high power to show flat, cubical epithelium.

surface. The portion which contained the fluid was lined with a
rough, grayish, granular colloid mass 0.5 cm. thick which could
be separated from the capsule. The lower half of the tumor
which was solid contained small round cysts; below them there
was a homogeneous colloid mass varying in color, some places
being grayish, others yellow, amber, and brownish.

Microscopical Examination, — ^The capsule consists of fibrous
connective tissue, in most places poor in nuclei and not very
well supplied with blood- and lymph-vessels. Sections show
the encapsulated mass to be made up of a framework of connec-
tive tissue undergoing hyaline degeneration in which are in-
numerable various-sized and shaped vesicles, most of them out-
lined by a single layer, some by several layers of cuboid, occa-
sionally cylindrical, epithelial cells. These cells contain large
nuclei having a fine chromatin network, and a comparatively
small amount of cloudy protoplasm; the borderlines between



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628 proescher: teratoma strumosum thyreoideale ovarh.





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Fig. 15.



Fig. 16.

J. H. Swanton's case. Brit. Gyne. Journal, 1907, p. 244.

Fig. 15. — Gross specimen.

Fig. 16. — Microscopical section. Zeiss, ocular 2; 'objective DD. A, Colloid
material, showing ghost cells with spaces occupied by fat crystals. B, Septum
between acini, showing cubical cells with nuclei.



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proescher: teratoma strumosum thyreoideale ovarii. 631

cells are very faint, often indistinguishable, giving a syncytial
appearance. The epithelium lies directly on the connective
tissue. The epithelial covering is partially smooth, partially
corrugated, and partially in the form of papilla. The largest
part of the epithelial lining of the monstrous alveoli is in a state
of beginning necrosis.

According to their contents, and the processes going on within
them, these vesicles may be divided into two groups: i. those
containing a clear, homogeneous colloid which they secreted, and



Fig. 17. — Case I. Werder-Proescher-Roddy. Photograph of gross speci-
men. i4. Carcinomatous degeneration. 5. Wall of evacuated cyst.

2. those containing a granular colloid in which are many frag-
ments of disintegrating cells undergoing colloid degeneration.

At some places in the connective-tissue framework, instead
of vesicles there are solid groups of cuboid and irregular shaped
epithelial cells, some of them are arranged in rosettes, others in
parallel rows, of three, four, or five, lying close together. In the
center of each of these groups colloid degeneration is taking
place, the first step in the formation of a new vesicle. New
vesicles are also seen being formed by a process of budding from
already mature vesicles.

Besides the round and oval alveoli there are labyrinthine
tubal formations lined by one or more rows of cuboid epithe-
lium, some show a small lumen, others are filled with colloid and



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632 proescher: teratoma strumosum thyreoideale ovaru.

desquamated epithelium. The protoplasm of the epithelial
cells is undergoing colloid degeneration; they contain large drops
of colloid which push the nuclei toward the periphery: some
cells from which the colloid has escaped show vacuoles. The
nuclei of these cells are round or oval and have a chromatin
network.

In most of these formations the outer part of the tubules are
formed by the epithelial cells, there being no membrana propria;
in a few isolated places there is a thin layer of fibrous connective
tissue between the tubules, parts of which present a sarcomatous
appearance.



Fig. 1 8. — Case II. We iss-Proescher- Roddy. Gross specimen.
Showing large cyst, filled with colloid mass.

Case II. — Woman twenty-six years old, borne two children.
Always enjoyed good health until seven months before admis-
sion to hospital. First symptom was irregular menstruation;
later bearing down sensation in pelvis. Two month's before
admission she first noticed abdomen enlarging. On admission
patient was in a weak and exhausted condition; heart, lungs,
liver, and kidneys normal, uterus retroflexed, large tumor pal-
pated in the region of appendix.

After opening the abdomen a large tumor of the right ovary
was removed. It was attached to the tube, had no peritoneal
covering. Macroscopic appearance: Oval; tumor measured
16x23x9 cm. and weighed 2,500 grams. When cut it was
found to have a fibrous tissue capsule 3 mm. thick. This oval
tumor was divided into two cysts, the upper, attached to the



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proescher: teratoma strumosum thyreoideale ovarh. 633

B



Fig. 19. Fig. 20.



Fig. 21.



Microscopical sections, about three times enlarged.

Fig. 19. — Tumor. Werder-Proescher- Roddy. Showing connective-tissue cap*
sule. Tumor mass, consisting of large and small follicles filled with colloid.
Follicles are separated by connective-tissue stroma.

Fig. 20. — Tumor. Weiss-Proescher-Roddy. A. Showing large and small
cysts filled with colloid, separated by connective-tissue stroma. B. Osteoid
substance.

Fig. 21. — ^Tumor. Simpson-Proescher-Roddy. Showing tumor mass divided
by connective- tissue stroma in two large locules which contain numerous small
follicles, partly filled with colloid.



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634 proescher: teratoma strumosum thyreoideale ovaru.

tube, when opened was found to contain a thick light gray fluid,
two cysts about 7 cm. in diameter, and one about 3 cm. in di-
ameter; these three cysts contained colloid.

The cyst forming the lower portion of the tumor measured
18x6x8 cm. and contained alveoli arranged in straight rows
which radiate like the ribs of an open fan, they vary in size the
average diameter being 3 cm. Some of the alveoli are filled with
a transparent grayish colloid, others with an opaque brownish
colloid, a few contain bone-like pale yellow masses hard to cut
with the knife.

In the wall of the upper cyst there are remnants of the ovary.

Microscopical Examination. — Capsule is composed of hyaline
degenerated fibrous connective tissue, poorly supplied with
blood and lymph-vessels and containing few nuclei. The con-
nective tissue dividing the tumor lobules is well supplied with
blood- and lymph-vessels, and is rich in nuclei. In places deep-
stained endothelium is seen upon its surface.

The intralocular masses are made up of a fine connective-
tissue network containing innumerable irregular-sized round
and oval vesicles lined with a single layer of cuboid or cylin-
drical epithelial cells which have large round or elongated oval,
basal staining nuclei. The most of these cells have very indis-
tinct outlines, others show no borderlines and appear as a band
of pink protoplasm containing a row of nuclei. Vacuoles are
seen in many cells marking the escape of drops of colloid. The
epithelial cells lining the vesicles have no membrana propria,
they rest directly on the connective tissue. Some alveoli are
filled with a bluish granular colloid in which are fragments of
disintegrated epithelial cells, undergoing colloid degeneration.
Others contain a clear, homogeneous, pink colloid mass. There
are areas in which alveoli can be seen forming and multiplying;
in such places the connective tissue is especially rich in nuclei.

The interalveolar connective tissue is well vascularized and
contains some large blood- and lymph -vessels; numbers of the
lymph-vessels are partly filled with colloid.

Scattered through the tumor are many small areas of osteoid
tissue, none of them show calcification. They consist of homo-
geneous and fine linear striated masses, stained red, containing
numerous well-formed bone-corpuscles.

Attached to the inner surface of the capsule is a small remnant
of the right ovary showing marked cirrhosis and a few corpora
albicantia, but no follicles.

Case III. — Woman thirty-seven years old, had several chil-
dren. Always in good health until six months before admission
to hospital, then she began to lose weight and strength, and
developed symptoms and signs indicative of pelvic tumor.
Her abdomen was opened and an ovarian tumor was found on
the left side attached to the tube; the right ovary was en-
larged and showed pathologic changes, but, owing to the patient's
poor physical condition, was not removed.



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proescher: teratoma strumosum thyreoideale ovarii. 635



Fig. 22. Fig. 23.



Fig 24. Fig. 25.



Fig. 26. Fig. 27.

Microscopical section from tumor No. i. Werder-Proescher-Roddy.

Fig. 22. — Zeiss. Oc. 4. Obj. 16 mm. Showing large cysts filled with colloid
and outlined with cubic epithelial cells surrounded by connective-tissue stroma.

Fig. 23. — Zeiss. Oc. 4. Obj. 8 mm. Showing the development of solid, round,
nonliquefied vesicles out of a ground substance consisting of round and spindle cells.

Fig. 24. — Zeiss. Oc. 4. Obj. 8 mm. Showing many small follicles and beginning
formation of a large cyst.

Fig. 25. — 2^iss. Oc. 4. Obj. 8 mm. Showing an isolated group of vesicles of
adenomatus type.

Fig. 26. — 2^iss. Oc. 4. Obj. 16 mm. Showing carcinomatous degeneration of
follicles in form of an adeno-carcinoma (labyrinth- like tubules).

Fig. 27. — 2^iss. Oc. 4. Obj. 4 mm. Same section as Fig. 5, only higher power
showing tubules outlined with a colloid degenerated cubic epithelial cells.



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636 proescher: teratoma strumosum thyreoideale ovaril

Macroscopic Appearance. — After fixation in formalin, 4 1/2X
3x2 1/2 cm., 80 grams weight, oval semisolid encapsulated
tumor surrounded by a connective -tissue capsule 2 mm. thick,
strands of which dip down into the tumor dividing it into small
lobules; it was a grayish color, and with a reading glass a great
many pin -head -sized alveoli could be seen.

Microscopic Examination. — Capsule : The greater part consists
of well-vascularized connective tissue rich in nuclei, and occa-
sional spindle-shaped and epithelioid cells. Some sections are in-
filtrated with deep-stained round cells, in some places more nu-
merous than in others. Parts of the capsule contain vessels whose
walls consist of only one or two layers of long spindle-shaped
endothelial cells. Such vessels are distended with blood. Lymph-



FiG. 28. Fig. 29.

Microscopical section, Case II. Weiss-Proescher-Roddy.

Fig. 28. — Zeiss. Oc. 4. Obj. 16 mm. Showing large cysts filled with colloid
and outlined with cubic epithelial cells surrounded by connective-tissue stroma.

Fig, 29. — ^Zeiss. Oc. 4. Obj. 16 mm. Showing large area of osteoid tissue
with well developed bone corpuscles.

vessels are seen in all sections of the capsule, many of them
containing colloid.

The encapsulated mass consists of a strongly developed con-
nective-tissue network in which are vesicles filled with colloid, also
cords and nests of epithelial cells. The connective -tissue network
varies in different parts of the tumor: in one place it consists of
closely lying fibers extremely rich in nuclei, having a sarcomatous
appearance, in another part epithelioid cells having round
or oval nuclei in which a few chromatin granules are seen, in a
third place it resembles embryonal connective tissue, myomatous
type, and some of it shows hyaline degeneration. Areas of
round-cell infiltration and large and small hemorrhages occur
here and there in the connective tissue. It contains many
blood-vessels exactly the same as those of the capsule. In a
few places there are small, corkscrew-like, thick-walled, partly



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proescher: teratoma strumosum thyreoideale ovarii. 637

hyaline degenerated vessels, some of which are occluded. In
the vicinity of such vessels many corpora albacantia, remnants
of the ovary, are seen. Lymph-vessels are not as numerous
as in the capsules, they contain colloid.



Fig. 30. Fig. 31.



Fig. 32.

Case III. Simpson-Proescher-Roddy. Microscopical sections.
Primary growth.

Fig. 30. — Leitz. Oc. 4. Obj. i. Showing various-sized vesicles filled with a
granular colloid mass and outlined with a multiple layer of irregular-shaped
epithelial cells. The follicles surrounded by a strongly developed connective -
tissue stroma.

Fig. 31. — Leitz. Oc. 4. Obj. 4. Showing vesicles by higher power with a
multiple layer of irregular-shaped epithelial cells and in the center a solid, non-
liquened, newly formed vesicle.

Fig. 32. — Leitz. Oc. 2. y'^ oil in^n^crsi^i^- Showing epithelial cells with hyper-
chromatic mitotic figures.

The vesicles are exactly like those seen in Cases I and II before
described, except that they are outlined with a multiple layer of
irregular-shaped epithelial cells; they contain many atypical
hyperchromatic mitotic figures.

Five months after removal of the tumor the patient returned



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638 proescher: teratoma strumosum thyreoideale ovaru.

to the hospital suflFering from a recurrence. When her abdomen
was opened, the right overy was seen to have enlarged and there
were many nodules in the mesentery and liver, one was removed
for examination and the abdomen closed. The bean-sized solid
metastatic growth removed from the omentum has the same
appearance as the primary tumor except that the connective
tissue is less in amount and contains relatively fewer cells; the
colloid is a very pale pink, and there are present many mono-
nuclear sessil -formed eosinophiles.

The distinction of being the first to clearly describe and properly
classify teratoma strumosum thyreoideale ovarii undoubtedly



Fig. ss. Fig. 34.

Microscopical sections. Case III. Simpson-Proescher-Roddy.
Metastatic growth from the mesenterium.

Fig. ^$. — Lcilz. Oc. 4. Obj. i. Showing various-sized cysts, partly colloid
degenerated, partly solid, surrounded by a strong connective-tissue stroma. The
large follicles are outlined by a multiple layer of irregular-shaped epithelial cells.
Follicles are filled with colloid and disintegrated epithelial cells. Above the two
large cysts in the center is a newly formed follicle with beginning colloid degener-
ation in center.

Fig. 34. — Leitz. Oc. 4. ^ oil imnwrsion. Showing eosinophiles in the con-
nective-tissue stroma.



belongs to Pick. The claims of Gottschalk and Kretschmar
to priority are untenable.

In his communications, prior to the appearance of Pick*s
critic, Gottschalk occasionally referred to his tumor as "Similar
to struma malignum," which is certainly not a phrase one would
use to convey the idea that it contained thyroid tissue; the term
"Struma malignum" is vague and does not convey a correct
idea of the pathologic anatomy presented by an ovarian tumor
composed of thyroid tissue.

Kretschmar's first report of his case was read before the



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proescher: teratoma strumosum thyreoideale ovarii. 639

Gynecological Congress at Giessen, two years before Pick's
original article was published ; at that time Kretschmar made no
reference to any similarity to thyroid tissue observed in his
tumor and his statements show he did not suspect any.



A
A

A I

A I
B E

B E
Str
B 2



Fig. 35. — Schroeder's case of "Folliculum malignum ovarii," drawing (Fig. 5).

A. Alveole. C. Protoplasma disk, high power.
Str. Stroma.
Fie 2 J B. E. Basal epithelium.
^' ] A. I. Protoplasma disks.
B. I. f Connective-
l B. 2. \ tissue stroma.
Archiv fur Gynaekologie, Bd. 64, Tafel 8, Fig 5.

After reading Pick's paper, Kretschmar wrote an article in
which he stated he belived Pick was right in that the tumor
removed by him was a struma thyreoideale ovarii; but wrong
in classifying it as a teratoma, it being a metastatic growth



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640 proescher: teratoma strumosum thyreoideale ovARn.

resulting from the lodgment in the ovary of emboli carried
from the thyroid by the blood stream.

Since the appearance of Pick's critic, Gottschalk has written an-
other paper on the subject, contradicting himself a number of
times. In his latest communication he refutes Pick's diagnosis
and declares his original one, *'folliculum malignum," correct.
He further states that his tumor developed from the wall of a
primative follicle and shows a strong similarity to so-called
folliculum. Pick has shown this idea untenable, and Gottschalk
has never offered any direct proof.

Because he found the smallest locules in the periphery of his
tumor, Gottschalk concludes it developed from the periphery



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