thelial cells. The wall of the alveoli consists of coarse fibrous connective tissue, richly supplied with blood-vessels. The endothelial cells are globular, fusiform, or polyhedral corpuscles, mainly arranged

Endothelioma of Ovary (Jones): C, coarse connective tissue containing V, large blood-vessels, mainly venous in character; S, septum or prolongation of connective tissue into a closed space filled with globular and angular corpuscles in rows; between the rows there are fat-globules and empty slits; 4, cellular elements.

in rows and intermixed with dark brown fat-globules and pigmentgranules.

The rows are in many places interrupted by light gaps, probably caused by liquefaction of some of these cells.

In the vicinity of an endothelioma there are large varicose veins and often aneurismatic arteries, which occasionally rupture, and cause hemorrhage under the albuginea or into adjacent cysts.

Sometimes some of the cells are transformed into red blood-corpuscles, while others fuse together, forming vessels around the newformed blood. (See Hematoma, p. 532.) The endothelial growth replaces gradually the normal ovarian tissue, and may occupy the whole

ovary, which, however, is not much increased in size, and sometimes even smaller than normal. The ova are diseased or destroyed.

The clinical features of endothelioma are lancinating pain in the region of the ovary, progressive emaciation, pronounced pallor, and great weakness.

By destroying the patient's health and rendering her sterile the affection is of great importance.

Both gyroma and endothelioma originate in chronic oöphoritis, and, again, they cause inflammation in the surrounding tissue. Some pathologists take endothelioma to be a variety of carcinoma, which fits well with the clinical aspect.

As the presence of these conditions can only be proved by microscopical examination, they cannot be a guide in regard to treatment, but when, after oophorectomy, they are found in the removed ovaries, they bear witness to the justifiableness of performing the operation.

CHAPTER V.

NEOPLASMS.

THE ovaries are very frequently the seat of neoplasms. Some are cystic, others are solid.

A. Cysts.

Pathological Anatomy.-Ovarian cysts offer a great variety in their anatomical structure, but they may, nevertheless, be reduced to a few

types:

I. Dropsy of the Graafian follicle (hydrops folliculi), assuming one of three forms: 1, a conglomeration of many small cysts in the interior of the ovary; 2, a similar formation, but with pedunculated cysts, by which the whole ovary may become like a bunch of grapes (Rokitanski's tumor); and 3, the development of a few or one large cyst; II. Proliferating cysts, occurring in three varieties: 1, glandular, 2, papillary, and 3, mixed: III. dermoid cysts; and, IV. tubo-ovarian cysts.'

While the author was collecting materials for his work on Diagnosis of Ovarian Cysts by means of the Examination of their Contents, he had the advantages of witnessing all the ovariotomies performed in the Woman's Hospital in the State of New York during eighteen months, and of obtaining a part of the fluid and the sac and the ovary of the opposite side when it was diseased. Not only was the fluid examined chemically and microscopically in every case, but many hundreds of specimens were cut from the hardened sacs or small ovaries. In that work he refers also in many places to the solid part of ovarian cysts, and if other occupations have prevented him from increasing the material and utilizing it for a special essay, his personal acquaintance with all stages of cystic degeneration of ovaries has enabled him to better understand and value the work of other investigators in this domain.

I. Dropsical Graafian Follicles.

In studying chronic oöphoritis we have seen (p. 535) that often in that disease many small follicles may be transformed into cysts, and

that a single follicular cyst may cause the absorption of the rest of the ovary. Thus there is a gradual transition from oöphoritis, an

FIG. 273.

Bilateral Oligocystic Ovarian Tumors (Hooper).

inflammatory disease, to cystic degeneration, a neoplasm, and it is in reality, in some cases, only the size of the specimen which decides us in calling the disease by one or the other name. The proof that a cyst is of follicular origin is the presence of the ovum; and by the conformity of the structure and the fluid we are led to regard larger cysts,

even when the ovum has disappeared, as being developed from follicles.

If many follicles are affected simultaneously (Fig. 272), the ovary does not obtain very large dimensions, indeed hardly more than the size of an hen's egg. The stroma may be unchanged or infiltrated with medullary elements. Gradually it is absorbed.

Sometimes a few follicles become cystic, forming what is called an oligocystic tumor (Fig. 273). Very rarely the partition between two

such cysts ruptures, so that they communicate. As a rule, only one is developed; or, predominating in its development, causes the atrophy and disappearance of the others.

If only one follicle undergoes cystic degeneration, it may form a tumor of the size of a man's head or even a uterus at term."

Such a large cyst is strictly monocystic. Nowhere are found remnants of partitions. The wall is white, and consists of two layers of dense fibrous connective tissue held together with a layer of loose connective tissue, in which run blood-vessels. The arteries are thickened in consequence of endarteritis. These two layers correspond probably to the tunica propria and the combined tunica fibrosa and albuginea (p. 68). The outside is covered with a short columnar epithelium; the inside has a similar epithelium with somewhat longer cells.

The fluid is serous, alkaline, and almost colorless. It does not coagulate spontaneously nor by heat. It contains paralbumin, the presence

Ovaries with Pedunculated cysts (Winkel): a, anterior wall of uterus cut open, showing a primary sarcoma of the body; b, c, ovaries with multiple pedunculate cysts; d, e, tubes; 7, posterior wall of bladder.

of which is characterized by its precipitation when the fluid is boiled with a small amount of acetic acid, the precipitate being redissolved by adding an excess of the same reagent. It contains only a few granules and no cellular elements.

These monocystic and oligocystic tumors are much rarer than the proliferating and dermoid cysts.

Rokitanski's Tumor (Fig. 274).-Much rarer still is that species

1 I have seen it contain a pailful of fluid (Diagnosis, p. 9).