through the capsule, it becomes scarred and pale; the capsule is thickened, and the ovary distorted. No two ovaries are exactly alike; some are round, some long, some of hourglass shape; some measure a half inch in length, others as much as two inches. In other words, there is the greatest variety among perfectly normal ovaries. But surgeons have spayed thousands of women because their ovaries did not conform to some ideal organ, and many of these women have been sent to the mad-house. Hystero-epilepsy, epilepsy, neuroses of all sorts, chronic pelvic pain, in short almost every obscure complaint in women, has been treated by the removal of ovaries that were cystic, apoplectic, or "atrophied." I believe that non-purulent ovaries produce few symptoms other than a sense of weight when they are large. When adherent in the cul-de-sac and compressed by other organs, they give pain; but it is the lack of freedom in mobility and position, rather than essential disease, which is to blame.

Periovaritis gives no distinguishing symptoms, inasmuch as it is always accompanied by some more important lesion, as salpingitis or pelvic peritonitis.

Ovarian Abscess can not be differentiated from pyosalpinx. The history will sometimes presumptively indicate the character of the abscess. Ovarian abscess is usually due to infection after abortion or labor, and when due to gonorrhea, it is found as a lesion secondary to salpingitis (Fig. 31). The symptoms are the same as those of pyosalpinx. Upon examining a pus-ovary case we do not get fluctuation. A firmly adherent, dense, sensitive mass is found to one side or behind the uterus. There are evidences of acute pelvic peritonitis, fever, pain, etc., just as are found with pyosalpinx. Still I have seen a case of an enormous pus-ovary holding a pint in which there was absolutely no evidence of fever.

Treatment.-Acute Periovaritis.— Inasmuch as this condition is not found existing alone, but as a concomitant of inflammation of other portions of the pelvic peritoneum, there is no special treatment to be directed to it.

Blisters and iodin applied to the abdomen over the ovaries are classical, but are of doubtful efficacy. I have found that the maintenance of a definite warmth over the abdomen by employing moist dressings which are covered by rubber tissue, painting the vault of the vagina with 10 per cent. to 20 per cent. ichthyol in boroglyceride, and keeping the bowels washed out so that hard fecal masses do not press on the ovaries, afford the greatest relief. If this condition is found to exist after a cul-de-sac operation is made, the ovaries should be detached from their false attachments.

Ovarian sclerosis cannot be cured by any means. Such ovaries may be removed when indications exist for removing the uterus, but sclerosis of the ovaries only does not warrant their removal.

Edematous ovaritis I have not met with except under circumstances which required removal of all the generative organs.

Cystic Ovaries.-Upon opening the cul-de-sac I first attempt to free the ovary of one side. When this is loose I introduce a posterior retractor into the pelvis, and with the trowel lift the uterus into the abdomen. A gauze pad is next introduced between the retractors, and

the head of the table is lowered. If the intestines are not adherent they will escape into the abdomen. The ovary is now grasped with Luer's forceps and pulled down. A pair of stout mouse-tooth forceps or bullet forceps may be substituted for Luer's instrument. The surface of the ovary is inspected carefully, and all cysts are stabbed with a tenotomy knife. The bleeding is trivial. When all the cysts are evacuated, the ovary is returned to the pelvis and the other ovary similarly treated. I am opposed to igni-puncture with the Paquelin cautery. This method of evacuation is uselessly complicated, and the healing after it is not normal. After returning the ovaries, the pelvis is wiped dry, and the gauze pad is

H

FIG. 32.-Suture of resection wound in the ovary.

removed. The rent in the cul-de-sac is sewed up, if the uterus is not retroposed, if the patient has not purulent endometritis, and if there is not pronounced oozing in the pelvis. When either of these exists it is better to introduce a plug of iodoform gauze into the opening and pack the vagina.

Ovarian Apoplexy.-Having released the ovary from false attachments, it is pulled into the vagina. In doing this care is exercised and the forceps should grasp the more normal portions of the organ. Steadying the ovary the surgeon splits the periphery of the blood-sac with scissors. Fluid and old blood escape and should be caught with gauze. Holding apart the lips of the rent, the lining cavity of the sac is easily pulled out. When this is removed it will be found to measure sometimes a

sixteenth of an inch in thickness. The cavity left after this will ooze a little, and the organ will appear much shrunk. Nothing more is needed where the apoplexy is small; but where the accumulation is large and its evacuation leaves flabby flaps, these should be trimmed and sutured (Fig. 32). The suture material may be either fine chromic kangaroo tendon or fine carbolized silk. The needles should penetrate beneath the cavity and a contin

uous suture be used. The ovary is returned, and, after cleansing the pelvis and removing the protecting pads, the opening in the vagina is either sutured or plugged with gauze. Of course, whenever retroversion accompanies either cystic or apoplectic ovary, the cul-de-sac is not to be closed, but is to be treated according to the method described elsewhere (see page 117).

Ovarian Abscess.-The treatment of this is similar to that of pyosalpinx, both as regards palliative operations and extirpation (Fig. 33).

BROAD-LIGAMENT CYST.

Upon examining the broad ligament spread out before a strong light, the various component parts of the par

FIG. 34.-Diagram of the structures in and adjacent to the broad ligament. a, Framework of the parenchyma of the ovary, seat of b, simple or glandular multilocular cyst; c, tissue of hilum, with d, papillomatous cyst; e, broad ligament cyst, independent of parovarium and Fallopian tube; f, a similar cyst in broad ligament above the tube, but not connected with it; h, a similar cyst developed close to ovarian fimbria of tube; j, the hydatid of Morgagni; k, cyst developed from horizontal tube of parovarium. Cysts e, f, h, j, and k are always lined internally with a simple layer of endothelium. 7, The parovarium; the dotted lines represent the inner portion, always more or less obsolete in the adult; m, a small cyst developed from a vertical tube; cysts that have this origin, or that spring from the obsolete portion, have a lining of cubical or ciliated epithelium, and tend to develop papillomatous growths, as do cysts in c, tissue of the hilum; n, the duct of Gärtner, often persistent in the adult as a fibrous cord; o, track of that duct in the uterine wall; unobliterated portions are, according to Coblenz, the origin of papillomatous cysts in the uterus. (After Doran.)

ovarium may be seen either as fibrous cords or as minute tubes (Fig. 34). Any infection passing from the uterus to the iliac glands through the lymph channels in the broad.