A. Cysts

In no part of the body are cysts so frequent, or so various as in the ovary, in the peritoneum, in the neighborhood of the internal sexual organs, or in the subperitoneal cellular tissue; as, for instance, between the laminae of the broad ligaments, and at the fimbriated extremities of the tubes. Moreover, the size attained by the ovarian cysts is extraordinary. It is more practical to consider all the different cysts at this place, though we shall parenthetically indicate the position they occupy in morbid anatomy, and have to revert to them in the sequel. At the bedside the term ovarian dropsy is equally applied to all cysts, provided they fluctuate. We commence with the simple formations, and pass on to those which, in reference to original development, structure, growth, pathological importance, and contents, are more complicated.

A. Simple Cysts

They are of very common occurrence. There are either one or several unilocular cysts in the ovary; at times they are even so numerous, that the ovary appears converted into an aggregation of cysts. They are placed near one another, each one being formed from the stroma, independently of the other, and they have a rounded form. If they enlarge, they come into mutual contact, their parietes adhere to one another, and they are flattened by reciprocal pressure; the impression may thus arise that several have, in the manner of the compound cysts, been formed within the parietes of the same matrix. They attain a considerable size, rarely, however, exceeding that of a man's head. In this case the solitary cyst, or one of several cysts, undergoes extreme development, whilst the remainder continue undeveloped. They generally have delicate sero-fibrous parietes, and may contain a colorless, or pale yellowish or greenish, serous, or a more consistent yellow, brownish, colloid substance, or an opaque chocolate-colored or inky fluid. In many cases they are undoubtedly formed from the Graafian follicles; and it appears that an inflammatory process is particularly liable to give the first impulse to this metamorphosis. They are probably, however, as often new formations from the beginning; and this is the more likely in those cases in which their number exceeds the average number of Graafian follicles. Allied to them are the adipose cysts of the ovaries; these we shall, however, discuss at a later period, on account of their numerous peculiarities.

3. Compound Cysts

They occur in the two forms described by Hodgkin. In the one, new cysts are formed in the coats of an older cyst, and although projecting into the cavity of the latter, they do not actually grow into it; the oftener this process is repeated, the more complicated the morbid product becomes. In the other, an endogenous generation of cysts is effected, cysts being formed upon the internal surface of another cyst, and being either sessile or pediculated; the matrix is sometimes entirely filled, the cysts discharge themselves into it and become adherent to it, and subsequently a third order of cysts may be formed within them, etc. The two forms are often seen in the same adventitious growth.

These cysts are capable of very extensive development; to them and to the following variety the large encysted ovarian dropsies are due. The separate cells or loculi contain the above-mentioned different sub-stnnces, and their parietes, especially those of older cysts, are generally of considerable thickness, and of dense texture. They, too, may probably in the first instance be developed from a Graafian vesicle as simple cysts, or they may form as adventitious growths; the remaining substance of the ovary is spread out at the base of the cyst; it is, as it were, thrown open, and its tissue condensed.

y. A third form, which very much resembles, and is closely allied to, the last, is of a cancerous nature, and belongs to the areolar variety of carcinoma. In the shape which we are about to describe, it rarely occurs anywhere but in the ovary. It is an accumulation of numerous fibrous sacs, which contain various substances, but for the most part a glutinous, viscid matter. They diminish in size from the circumference towards the interior, and especially towards the base of the morbid growth; so that the latter represents a condensed alveolar mass, the alveoli or follicles of which consist of a white, shining, fibrous tissue, and contain a colorless or grayish, yellowish, yellowish-green, or reddish viscid gelatine. We have here an areolar cancer, the peripheral follicles of which are converted into large sacs. This species of ovarian dropsy, which, for the sake of distinction from the other varieties, we term alveolar dropsy, is proved to be malignant, not only by its being accompanied by well-marked cachexia, but also by its complication with cancer (especially of the medullary variety) in the same organ, and with other varieties of cancer in other organs, as the peritoneum, or the stomach, and moreover by its complication with mollities ossium.

As already remarked, it attains an enormous size, and like the composite cysts, occasionally exists in both ovaries at the same time. In the composite as in the alveolar cyst, one peripheral follicle is subject to preponderating growth, and establishes ovarian dropsy.

To the above special observations we add the following remarks as important for the diagnosis. Generally but one ovary is affected, though the two are often attacked successively, so that the increase of size is much more considerable in one than in the other.

The enlarged ovary remains within the pelvis as long as it does not exceed certain dimensions; it either continues freely movable between the uterus and its lateral appendages and the rectum, or becomes fixed, and, as it were, wedged in by the formation of false membrane. If it increases still further, and is adherent to the pelvis, it grows into the abdominal cavity; otherwise it leaves its previous position, and rises into the abdomen, where it continues movable, until, in consequence of peritoneal inflammation, it has formed adhesions with adjoining viscera, or becomes fixed by entirely filling out the cavity. In the course of this change of position, it drags the uterus after it by means of its ligament, so that this organ, together with the vagina, is not only elongated, but obtains a slanting form, which is recognizable by the oblique and elevated position of the os tincae. (Page 214 and 215).