nent tissues are precisely those which have
been already described as characterising the
ovisac in its normal condition ; the chief
bulk of their texture being made up of gra-
nules and embryonic fibres intermixed with a
few developed fibres of ordinary white fibrous
tissue.

Such a condition may, for want of a better
designation, be regarded as hyperaemia of the
follicle, or it might perhaps be more appro-
priately termed hypertrophy of the follicle ;
but in whatever light it may be regarded, it
constitutes one of the early stages of those
enormous growths, of which more will be said
hereafter.

A more extensive form of congestion, affect-
ing the parenchyma of both ovaries, and as-
sociated with a like hyperaemic condition of the
uterus, may be sometimes observed about the
period of the final cessation of menstruation.
The ovaries are then occasionally found of an
intense red colour, from the parenchyma, as
well as the follicular walls, being deeply loaded
with blood. The most marked instances of
this I have observed in connection with car-
diac disease, and associated with congestion of
other organs.

Inflammation of the Ovary. Ovaritis.
Oophoritis. Our knowledge of the patholo-
gical changes which the ovary undergoes as
the result of inflammation, is chiefly derived
from examination of the bodies of women
who have died of acute puerperal metro-peri-
tonitis. But unquestionably inflammation
both in the acute and chronic form may affect
the substance of the ovary, independently of
the puerperal or pregnant states, and cause
various degenerations of the tissues of that
organ, as evidenced by those serous, fibrinous,
and puriform deposits, or general softening of
the ovarian parenchyma, which are occa-
sionally found after death. It is probable
also, from symptoms displayed during life, that
inflammation, especially in a chronic form,
not unfrequently attacks the ovary and termi-
nates in resolution, or in those milder results
of inflammation which consist in temporary
induration or enlargement of the organ, unac-
companied by serious disintegration of its
tissues.

It must, however, be observed with regard
to the evidences of inflammation of the ovary
either in the acute or chronic form, which are
supposed to be afforded during life, consisting
in pain and tenderness referred to the seat of
that organ, or in obvious enlargements of the
ovarv, as discoverable by various modes of
internal or external tactile examination, and
conjoined with more or less constitutional dis-
turbance, that these signs may and do often
in the non-puerperal state, accompany the
natural process of ovulation, and that such
symptoms, recurring with each menstrual pe-
riod, may affect a woman at intervals in a
greater or less degree during the whole of that



period of life in which she is capable of child-
bearing. But in the present state of our
knowledge of ovarian processes it is perhaps
not possible to determine how much of these
symptoms may be regarded as evidence of a
natural, and how much of a morbid change in
the part ; for although in many women the
process of ovulation is continually performed
without consciousness of local suffering, yet
in a great number of instances the act is
accompanied by much pain, and there can be
no question that the cause of much of this
suffering is to be looked for in the changes
which the tissues of the ovary undergo in the
act of expelling the ova.

How closely this process in its more ob-
vious conditions is allied to inflammation has
been already shown. A high degree of vas-
cularity of the part, with increased exudation
of fluid, and consequent enlargement and ten-
sion of the entire organ terminating in spon-
taneous laceration of its coats by a process
very similar to ulceration, and often accom-
panied or preceded by a more or less consi-
derable escape of blood : these together form
a combination or series of processes closely
allied in their nature to inflammation, and
frequently evidenced externally by signs usually
regarded as characteristic of inflammatory
action.

Nor is it yet known how far these sym-
ptoms, which have generally been assumed to
indicate ovarian inflammation, especially in a
chronic form, may be merely the external evi-
dences, not of natural, but of aberrant or dis-
appointed ovulation. For just as an abscess
is painful generally in exact proportion to the
unyielding nature or tension of the parts by
which it is surrounded, so it is probable that
when the follicle or the entire ovary becomes
tense from the effusions which have been
shown to have taken place ordinarily within
it, and this tension is not relieved because
rupture does not occur at the proper time, so
that ovulation is disappointed or is aberrant,
the symptoms which might be expected to ac-
company such an interrupted process would
be those which are usually set down as indi-
cating inflammation in a part.

This matter appears hitherto to have been
hardly thought of, and yet it is probable
that to abortive or interrupted ovulation may
be referred the commencement of many of
those morbid conditions of the ovary which
are not either malignant or the direct results
of inflammatory action. Probably many of
the cystic diseases of the ovary originate in
this way. Of disappointed ovulation, as it
may be observed in animals, instances have
been given at page .568. Here the follicles,
although apparently preparing for rupture,
were arrested in their progress from some un-
explained cause ; and although it may be con-
jectured that such follicles might, under an
increase of stimulus, accomplish their final
purpose, as Coste has supposed in reference
to the instance just quoted, yet it has been
shown by the researches of Barry that mul-
titudes of ovisacs perish without accomplish-



OVARY (ABNORMAL Ax ATOM v).



ing that purpose at all, and it is probable that
these, in preference to other and more healthy
follicles, become the seat of subsequent mor-
bid changes.

For it must be remembered that the cir-
cumstances under which the male and female
generative elements escape from the place of
their original formation are essentially dif-
ferent. The male secreting organ, the testis,
is provided with an excretory duct for the
escape of the fertilising fluid ; but the female
gland is a shut sac. To the normal escape
of its products many barriers are opposed,
and it has already been shown by what com-
plicated machinery the shedding of the female
product is effected. But it is impossible to
regard this complex process without perceiv-
ing how easily a failure in any of those steps
may defeat the final object for which that
process is set on foot. The thickness of the
walls of the follicle, the density of the ova-
rian coverings, or of the parenchyma of the
ovary, if the follicle should fail to reach the sur-
face ; the chance of the ovum perishing before
it quits the ovisac, and so the stimulus to the
healthy development of the latter being lost ;
the chance of an excessive accumulation of
liquor folliculi or of blood within the follicle,
causing damage to the ovum, and replacing
a natuial by a morbid amount of exudation.
In these and other possible interruptions to
the natural completion of ovulation we may
discover the elements of many future morbid
changes. And although it would require a
long continued and deep research into the
aberrant functions of the ovary to determine
the true order and sequence of many of these
morbid processes, yet it is impossible to carry
anatomical investigation into the structure of
the morbid ovary, especially under incipient
forms of disease, to any extent without many
fragmental observations occurring suggestive
of the idea that the ovary, like any other
gland, may have its natural functions'impeded,
and that many of the organic changes which
are observed in this part may owe their origin
to such interrupted processes. Some of the
observations which have led me to the adop-
tion of these views have been already given,
and some others will be detailed as suggestive
of a better basis for the study of "ovarian
pathology than has hitherto been employ ed ;
for of all the organs of the body the ovary is
perhaps that whose pathological conditions
have been regarded with the smallest amount
of reference to its natural or deranged func-
tions.

From these considerations, then, I have been
led to the conclusion that certain conditions
of the ovary, which, from their concomitant
symptoms during life have been deemed in-
flammatory, are not necessarily associated with
inflammation ; that it is probable, first, that
the natural process of ovulation is often ac-
companied by symptoms very similar to those
of inflammation ; and secondly, that the pro-
cess of ovulation is occasionally disappointed
or interrupted, and that the follicles, whose
Sup p.



77

natural development has been interrupted,
may, like the hydatiform placenta, become the
seat of a low form of nutrition, terminating in
effusion and collection of various dropsical
fluids.

With regard to the anatomical evidences of
inflammation of the ovary as furnished by
post-mortem examination, they are chiefly the
following, viz. : general redness or hyperaemia
of the ovarian parenchyma, or of the walls of
the follicles ; swelling of the ovary to the ex-
tent of increasing the organ to three or four
times its natural size, producing a round, oval,
or flattened form of the ovary ; a general tension
or hardness of the organ in the early stages of
inflammation, and subsequently softening, con-
sequent on degeneration of the tissues and
their infiltration by serous or puriforin effu-
sions ; and lastly, but rarely, gangrene of the
ovary.

Of these morbid changes the only one which
appears to require a more particular account is

Suppuration of the ovary. Pus may be
found in a circumscribed cavity within an en-
larged and highly vascular ovary, portions of
whose structure may still retain its natural
condition. Or the entire ovary may be con-
verted into a bag of pus, the natural tissues
being entirely destroyed, and the fluid bounded
only by the ovarian tunics. In such cases
the abscess " appears to rise from suppuration
in the substance of the viscus, similar in
every respect to phlegmonous abscess in any
part of the body, and not connected with any
cyst, or change, or addition of structure, the
product of morbid growth."* These abs-
cesses, which are sometimes of enormous size,
may burst into the general sac of the peri-
toneum, or, after forming adhesions with sur-
rounding parts, may discharge their contents
externally through the abdominal walls, or
into the Fallopian tube, uterus, vagina, blad-
der, rectum, or other part of the intestine.
Portal mentions cases of ovarian abscess as
large as an infant's head, and Dr. Taylor f of
Philadelphia has recorded an instance in which
the ovary contained twenty pints of pus. It
is highly probable that these and even still
larger collections of pus, which have been
found in the ovary, were, as M me Boivin has
suggested, originally cases of encysted ovarian
dropsy, but inflammation and suppuration
having been set up in the walls of the cyst,
the original contents have been gradually in-
termixed with pus, until the whole fluid has
appeared to be of that nature. Probably of
this kind also was the case recorded by VaterJ,
in which the ovary was as large as the human
head, and " contained pus distributed into
several capsules." This, therefore, was a
multilocular abscess.

Except in connection with acute metro-
peritonitis, suppuration of the ovary may
be considered as comparatively rare. Dr.

* Seymour's Illustrations of some of the principal
Diseases of the Ovaria, p. 40.

t North Amer. Med. & Surg. Journ. 1826.
i Haller, Disp. Med.

P P



578



UTERUS AND ITS APPENDAGES.



Hooper* " met with only two instances of
abscess" of this organ. "The one was the
size of a child's head at hirth, the other not
larger than an orange. There was nothing in
these different from common abscesses ; the
whole of the internal substance of the ovaries
was gone, and the walls were formed of a
thick and mther ligamentous cyst, covered by
peritoneum." Suppuration occurs also occa-
sionally in those cysts of the ovary which con-
tain hair and teeth, together with other im-
perfectly formed products. To the same class
of suppurative diseases should also probably
be referred that singular morbid condition of
the part in which the entire ovary is reduced
to the state of a diffluent pulp, of a yellow or
brownish-green colour, of the consistence, and
having somewhat the appearance of very soft
putty, immiscible with water, and retaining
sufficient tenacity to preserve its semifluid
character, and yet not having firmness enough
to admit of the part being preserved as a pre-
paration. Of this morbid condition of the
ovary, which, however, may possibly be can-
cerous, I met with a striking example in a
case of sudden death occurring in the seventh
month of pregnancy. Both ovaries were of
the size and form of a bullock's kidney, their
natural structure was entirely destroyed, and
was replaced by the soft substance just de-
scribed. The circumstance that both ovaries
were thus affected renders it evident that the
disease could not have existed in any great
degree at the time of impregnation, or that it
certainly must have been then limited to one
organ.

From the comparatively scanty materials
extant relating to ovarian abscess it may be
concluded, that suppuration may either com-
mence at separate parts of the parenchyma,
forming small collections of matter, which
gradually coalesce, or it may be set up through-
out the whole of the stroma at once. In these
cases the parenchyma of the ovary is gradually
consumed, and the organ is converted into a
purulent cyst.f Whilst in other cases the
Graafian follicle appears to be the seat of the
suppurative action, which may either com-
mence originally in the walls of one or more
follicles constituting circumscribed abscesses
of moderate size, or the suppurative stage of
inflammation may be established in the walls
of a follicle already considerably enlarged, and
thus an ordinary ovarian cyst, with simple
transparent contents, may be gradually con-
verted into an abscess of enormous magnitude.

Cysts. A complete anatomical description
of the numerous forms of cystic disease which
affect the ovary would occupy a far larger
space than the limits of this article will per-
mit. On this account the more important
varieties only can be noticed. These are
chiefly Simple cysts, Compound cysts, Hy-
datid cysts, Demoid cysts, or those contain-



* The Morbid Anatomy of the Human Uterus
and its Appendages, p. 3.

t Rokitansky, Path. Anat. vol. ii. p. 331. Syd.
Soc. edit.



ing fat, hair, teeth, and bones, and Colloid
cysts.

Simple Cysts. The simple, barren, or uni-
locular ovarian cysts are composed, as their
name implies, of a single sac, which, accord-
ing to its size, occupies the interior of the
ovary, whilst the rest of the organ retains its
normal condition ; or else the cyst, by en-
larging, presses aside and distends the paren-
chyma and tunics of the ovary, which thus
form a common boundary to the sac, or the
cyst, having originated in one extremity of the
ovary, grows at the expense of that portion
of the organ, whilst the rest, retaining its
natural structure, becomes by degrees a mere
appendage of the sac, and may be seen pro-
jecting in the form of a small button-like pro-
minence from its outer surface.

These cysts vary in size from that of a pea
to the bulk of the adult head ; they rarely,
however, attain the latter dimensions without
becoming proliferous or multilocular, and they
appear never to acquire as single cysts the
enormous bulk which the compound cysts not
unfrequently exhibit. This more moderate
size of the single cyst is less frequently pro-
ductive of those adhesions with surrounding
parts which the pressure of the larger com-
pound cysts so commonly occasions. Hence
the precise locality of the single cyst, and its
origin in the substance of the ovary, can
generally be determined without difficulty.
The distended sac is found hanging as an ap-
pendage to the ovarian ligament, whilst the
Fallopian tube is often seen partly spread out
over its surface, one of the fimbriae being
always closely adherent to the sac, and con-
ducting the observer infallibly to any portion
of the original ovarian structure which may
have remained yet unchanged.

The coats of these cysts vary much in density
and thickness. Those of the single kind are
more uniform throughout ; they are generally
thickest towards the base or seat of their vas-
cular supply. Here they vary in thickness
from 2'" to 12'", but become much thinner in
other parts, so as at times to be nearly trans-
parent. The outer coat always consists of
peritoneum, which is smooth and shining upon
its surface, except when adhesions have been
formed with surrounding parts, or when fatal
peritonitis has occurred, as from bursting of
the sac. The condition of this coat has been
already described under the head of morbid
states of the ovarian tunics. The variations
in its thickness are not generally so consider-
able as materially to affect the bulk of the
sac.

The middle or intermediate coat is that ge-
nerally upon which the greater or less density
of the cyst wall depends. This coat is usually
of a brownish-yellow colour, and firm fleshy
texture. It is with difficulty split into a
number of rough -surfaced laminae, exhibiting
to the naked eye a coarse fibrous arrangement
of their constituent parts, which, under the
microscope, are seen to consist of inelastic
fibrous tissue, mingled with granules, and
undeveloped fibre cells in varying proportions.



OVARY (ABNORMAL ANATOMY).



To this coat, which appears to retain or in-
crease its thickness by a perpetual new for-
mation of fibrous tissue, is due that support
and resistance to the pressure of the in-
creasing contents of the sac, which prevents
the more frequent rupture of these cysts. And
it is probable that when the latter phenome-
non occurs, without the formation of previous
adhesions, followed by ulceration, the lacera-
tion is due to the gradual attenuation of the
middle wall of the sac.

Occasionally portions of these walls are
found to be of nearly cartilaginous hardness,
so that they can with difficulty be broken up
into fragments for minute examination. Such
portions are seen under the microscope to be
composed almost entirely of close-lying fibres
of white fibrous tissue, with scarcely a trace
of the embnonic fibres and granules, which
are found abundantly in the walls of the softer
cysts, and of the normal ovisac. Other por-
tions of these cyst walls, still more dense,
present to the naked eye, as well as under the
microscope, all the characters of the simpler
forms of cartilage ; whilst in the walls of
other cysts again are found patches of ossific
matter, in which the earthy elements of bone
are aggregated together, (calcification) but
without the definite arrangement characteris-
tic of true osseous structures.

Upon and in the substance of this middle
coat ramify numerous arteries and veins, some-
times of considerable magnitude. These dis-
tribute their minute branches upon the inner
surface of the cyst, where they occasionally
present a peculiar straight or rectangular ar-
rangement. Doubtless these vessels are the
carriers of those enormous collections of fluids
which accumulate within the cysts, and upon
their arrangement, as well as upon the nature
of the epithelial lining of the sac, depends
probably the character of the fluids secreted
or effused.

Most variable is the condition of the lining
membrane which bounds the inner surface of
the cyst. In the smaller cysts it is often com-
posed of one or more layers of simple flat-
tened epithelial cells ; the remains, perhaps,
of themembranagranulosa. This surface may
be free, or to it may adhere fragments of blood
clot, degenerating or undergoing fibrillation, by
which the sac, when small, is partly filled.
This lining of epithelial cells is often seen in
a state of fatty degeneration*, and similar
cells are found abundantly scattered among
the contents of the sac.

In the larger and older cysts the membrane
lining the sac is nearly as smooth as that which
covers it externally. In these the lining
membrane often exhibits but little vascularity,
and shows small traces of an epithelial cover-
ing in its smoother parts, where it is usually
so intimately adherent to the middle walls, as
to be separable from the latter only with diffi-
culty. Fragments so obtained "are easily
split up, ancf are seen to be composed of deve-
loped fibres of connective tissue, intermixed

* Wedl, Patholog. Histol. p. 461. Syd. Soc.



579

with fine granules and a few embryonic
fibres.

After the simple cyst has arrived at a cer-
tain period of its growth, and generally when
it equals the size of a large orange, it begins
to exhibit upon its inner surface patches, more
or less extensive, of rough projections, gra-
nulations, or vesicles, which will be described
more fully under another section.

Multiple Cyits. I have employed this term
to designate a variety of the single cyst which
might be confounded with the compound or
proliferous kind, and which consists merely in
an aggregation of two or more simple cysts
that have been contemporaneous in their
growth. The distinction between a mere ag-
gregation of simple cysts and the growth of
a compound one has been carefully drawn by
"Rokitansky*, and has been also illustrated by
Paget.f

If such cysts are observed at an early
period of their growth, they may be seen to
occupy different portions of the ovary in which
they arise independently of each other, and
having distinct portions of ovarian stroma
interposed between each. They have at first
a round or oval form, but " as they all enlarge
together, and sometimes by the wasting of their
partition walls come into communication, they
are flattened by reciprocal pressure, and " may
at length look like a single many-chambered
cyst, having its one proper wall formed by the
extended fibrous covering of the ovary. Many
multilocuhir cysts, as they are named, are only
groups of close-packed single cysts ; though
when examined in late periods of their growth,
and especially when one of the group of cysts
enlarges much more than the rest, it may be
difficult to distinguish them from some of the
proliferous cysts.

Figs. 392. and 393. serve to illustrate the
simple and the multiple cyst respectively.
fig. 392. has been described at p. 575, where
this example is given as an instance of hyper-
trophy of a Graafian follicle in an early stage,
forming a simple or unilocular cyst, still
hardly contained within the substance of the
ovary. It will be seen that at one part of this
preparation the wall of the cyst has become
blended with the general investments of the
ovary ; and it will be easily understood how,
bv the gradual enlargement of the cyst in this
direction, where there will be the least amount
of resistance to its growth, the sac may at
length become so greatly expanded that the
remaining healthy portion of the ovary will
appear only as an appendage to it, or may
become by pressure and extension altogether
obliterated. Fig. 393., taken from Dr.Hooper's
collection , offers a good example of the mul-
tiple cyst. It is composed of a mere aggre-
gation of simple or unilocular cysts, which,
by coincident enlargement, have come at length
to fill the entire ovary, causing considerable
increase in bulk of that organ. From the
right ovary (a) a portion has been removed

* Loc. cit. p. 332.

f Lectures on Surgical Pathol. Vol. ii. p. 56.
J Morbid Anatomv of the Huuian Uteru*.
1> p 2



580



UTERUS AND ITS APPENDAGES.



exhibiting a section of several simple cysts of
nearly equal size ; whilst the left ovary (6)
shows a similar alteration of texture, the



organ being still unopened, and exhibiting
numerous small sacculi which have here begun
to project above the surface.



Fiff. 393.




a, right ovary, exhibiting numerous unilocular cysts, consisting of enlarged Graafian vesicles; b
"left ovary similarly affected, but unopened ; c, uterus. (After Hooper.}



Multilocular, Compound, or Proliferous Cysts.
In these a second, or, it may be, a third,
order of smaller cysts are developed, within