the uterus is normal. Women without Graafian follicles do not menstruate, and are sterile, but may have sexual desire and a perfect female type.

Rudimentary ovaries are often found together with an imperfect development of the large blood-vessels, especially the aorta, or of the central nervous system, especially in idiots and cretins.

CHAPTER II.

DISPLACEMENTS.

ONE or both ovaries may occupy an abnormal position. In its unusual place the ovary may have preserved its normal connections, or it may have been cut off altogether from the broad ligament by an inflammatory process in fetal life. It may then either float about as a small hard body in the abdominal cavity or it may become fastened to the lower border of the omentum.

If the displaced ovary retains its normal connections with the ala vespertilionis and the tube, it may be found outside the pelvis or remain in it.

Extrapelvic Displacements.-It may be found in the lumbar region, or, passing through the same openings as other herniæ, it may occupy the inguinal canal or the labium majus (inguinal hernia); the anterior side of the thigh below Poupart's ligament (crural hernia); the gluteal region (gluteal hernia); the depth of the anterior wall of the pelvis (obturator hernia), or the anterior surface of the abdomen (ventral hernia).

The position of the ovary in the lumbar region is very rare. It is due to a lack of descent (p. 23), and is only found together with a considerable arrest of development in other respects.

Inguinal hernia of the ovary may be congenital or acquired. The congenital may be due to a deficient development of the round ligament, by which the ovary, tube, and sometimes one horn of a uterus bicornis and part of the omentum are pulled through the canal of Nuck.

More rarely the ovary alone is found in a congenital inguinal hernia, into which it easily drops during intra-uterine life on account of being much smaller than the caliber of the canal of Nuck.

The acquired form can only occur if the tube and the infundibulopelvic ligament are unusually elongated and lax, and may then be produced by a fall or similar violence.

In its abnormal place the ovary may become inflamed or undergo cystic or cancerous degeneration.

Congenital inguinal hernia cannot be replaced. It may be pro

tected by a hollow pad or, if it gives trouble, it may be extirpated. The acquired form may be brought back through the canal and kept back by means of a truss or the radical operation for hernia. If it cannot pass the canal, herniotomy should be performed. If the ovary is seriously diseased, it should be extirpated.

Crural ovarian hernia is always acquired. If the ovary cannot be replaced by taxis, herniotomy should be performed, after which a truss should be applied. It should only be removed, if it is so seriously affected that medical and palliative treatment must be without avail.

The other herniæ through natural openings are exceedingly rare. The ovary may be found in a ventral hernia after laparotomy, and would offer a special indication for operating on the hernia.

The ovaries may also be drawn with the tubes into the funnel of an inverted uterus (p. 462).

While the preceding displacements are anatomical or surgical curiosities, the intrapelvic displacement or prolapse of the ovary, is a common disease of considerable practical importance.1

The normal ovaries may frequently be palpated in their normal situation by bimanual vagino-abdominal examination. They may likewise be felt by recto-abdominal examination, but the latter offers no advantage except in intact virgins or women with atresia of the vagina.

When the ovary becomes displaced it sinks backward, downward, and inward, describing an arc with the ligament of the ovary as a radius and its insertion on the uterus as a center. Thus it sinks first down on the retro-ovarian shelf (p. 91), and next into Douglas's pouch, and may sink as low down as the level of the os uteri.

Etiology. The left ovary is much more frequently prolapsed than the right, the cause of which is probably to be sought chiefly in the absence of a valve in the ovarian vein on this side, and its opening into the renal vein under a right angle-circumstances that favor passive hyperemia in the gland and predispose to disease (p. 74). The presence of the rectum on the left side and the motion of hard fecal lumps downward help also to dislodge the ovary.

The mere increase in weight of the ovary is sufficient to cause it to prolapse, as is proved by cases in which, after the subsidence of swelling, the organ returns to its normal place. It may be pushed out of place by tumors or drawn down by a retroverted or retroflexed uterus or by adhesions remaining after pelvic peritonitis. may also sink on account of insufficient support from below, especially rupture of the vaginal entrance (p. 305).

It

This disease has been treated of in an exhaustive way by P. F. Mundé, Trans. Amer. Gyn. Soc., 1879, vol. iv. p. 164 et seq.

Prolonged sexual irritation may cause the prolapse by producing hyperemia.

Pregnancy offers particularly favorable circumstances for the production of prolapse, since the ovaries are enlarged and ascend into the abdomen, and their attachments become softened and elongated. Inflammation and beginning cystic degeneration increase the weight, and are often the cause of adhesions.

Whether a normal ovary can become prolapsed by a fall or similar injury, as is the case with the uterus (p. 454), is doubtful, but if it is enlarged beforehand, such a traumatic impulse is enough to cause the displacement.

Prolapse of the ovary is frequently associated with acquired anteflexion of the uterus, the cause of both troubles being probably subinvolution after pregnancy and the concomitant lack of tonus in the tissues.

It is also often combined with tubal disease.

Symptoms.-The symptoms are those of chronic oöphoritis combined with those due to the abnormal position of the ovary. Hyperemia, edema, and inflammation may be both the cause and the effect of the displacement. The patient complains of pain in the sides of the pelvis, the sacral region, or the rectum, often shooting down to the knee and up into the hip. It gets worse when she walks, prevents her from standing for any length of time, and is sometimes aggravated by sitting down. It is also increased very much by palpation, and may continue through the whole day upon which the examination has been made. This great tenderness also renders coition painful or impossible, and causes great pain during the passage of hard fecal masses, and often painful tenesmus after they have been expelled.

Menstruation is, as a rule, painful and often too profuse.

Some

Nausea and vomiting are not rare. The whole nervous system suffers much. The patient is tired, despondent, and irritable. times she may even have attacks of epilepsy.

Diagnosis.-The diagnosis is, as a rule, easily made by bimanual examination, when the ovary is recognized by its shape, its connection with the uterus, its great sensitiveness if it is inflamed, or at least a sickening feeling on pressure if it is normal. If the ovary is situated on the retro-ovarian shelf, it is felt best by examining the patient in the left-side position and pressing the perineum well back.

The swollen tube has a more sausage-like shape. A small pedunculated fibroid of the uterus is harder and not sensitive. Remnants of pelvic inflammation are more diffuse and less tender. Scybala are less tender, may often be indented or crushed, and may be removed by enemas and aperient medicines.

Prognosis. The displaced ovary is liable to become inflamed or

cystic. If it is movable, the prognosis is comparatively good; but if it is bound in its new position by adhesions, the treatment will at best be a very protracted one, and a cure is doubtful.

Treatment. The two chief indications are to combat hyperemia and inflammation and to replace and retain the ovary in its normal place. The first is aimed at by rest, keeping the bowels open (p. 225), prohibiting sexual connection, prescribing hot vaginal douches (p. 171), using scarification of the cervical portion (p. 186), making applications of iodine (p. 170), or inserting pledgets with ichthyolglycerin (p. 178) into the vagina, or by means of galvanism with the positive pole in the vagina (p. 232).

The displaced organ should be replaced as soon as feasible, but sometimes the above-mentioned measures must be taken first before the ovary recovers sufficiently to be able to bear the pressure of a pessary.

The ovary is best replaced in the genu-pectoral posture (p. 138), and if it cannot be replaced or retained at once, the daily use of this posture and a glass tube admitting the air into the vagina (p. 447) may prepare the way for its final replacement.

If the ovary is adherent, it is necessary first to try to bring about the stretching and absorption of the adhesions. This is done by packing the vagina (p. 178). If the ovary is very tender at first, perhaps only a single cotton ball will be tolerated, but gradually more are put in, so as to lift the ovary up in the pelvis.

Massage (p. 190) is also a powerful means of stretching and breaking up adhesions.

The galvanic current has, in consequence of its electrolytic property (p. 232), a similar effect.

Schultze's method is somewhat similar to that used by the same author for uterine adhesions (p. 450). The forefinger is introduced into the rectum of the anesthetized patient in the lithotomy position, and bored in between the ovary and its surroundings, while the uterus is grasped with the other hand through the abdominal wall and pulled upward.

The retention of the ovary in its normal position is often more difficult than its replacement. Sometimes Thomas's hard-rubber bulbpessary, essentially a Hodge pessary (Fig. 250, p. 446) with a thickened upper arch, answers a good purpose. Special pessaries of hard rubber with a crossbar of unusual width, or with a notch in the middle or a corner cut off, have been constructed for this condition.1 In cases in which no hard pessary can be tolerated, one of whalebone covered with soft rubber (p. 447) may be tried.

If these measures fail, we may have recourse to cutting operations. If the uterus is retroverted or retroflexed, it may be brought forward

See the above-mentioned article by Mundé.

by shortening the round ligaments (p. 448) or fastening the fundus uteri to the abdominal wall (p. 452).

If the uterus is not displaced, but the ovarian displacement is due to an elongation of the infundibulopelvic ligament, that may be shortened by taking a reef in it (p. 453).

But if the ovary, besides being prolapsed, is diseased, the proper thing to do is to perform salpingo-oophorectomy, especially by vaginal section (p. 453).

CHAPTER III.

HYPEREMIA AND HEMATOMA.

A NORMAL hyperemia doubtless takes place in the ovary during coition in consequence of contraction of the unstriped muscle-fibers of the broad ligament (p. 57), and contributes to the expulsion of the ovum (p. 74). A similar normal hyperemia probably returns at regular intervals, corresponding to menstruation. At least the general blood-pressure of the whole system is increased before menstruation sets in (p. 117), and in some women a very considerable increase in size may be found alternately in one ovary or the other at the menstrual periods (p. 120). An effusion of blood also takes place normally into the ruptured follicle after the expulsion of the ovum (p. 71).

Pathological Anatomy.-Abnormal hemorrhage may take place into the Graafian follicles or into the stroma of the ovary, the follicular being much more common than the stromal. Follicular hemorrhage forms a tumor that is rarely larger than a hazelnut (Fig. 283), but may reach the size of a walnut.

The ovary is only moderately enlarged and a little more resistant. If many follicles are filled with blood at the same time, it is dark and studded all over the surface with small protuberances. The sac is thinned on the side nearest the surface. The contents are dark, thin blood mixed with clots. In the course of time it may change into a thick chocolate-colored fluid, which may be of the consistency of honey. The fluid part may be absorbed altogether, leaving a granular pigment; or the solid parts may be absorbed, so that only a cyst filled with serous fluid remains; or suppuration may set in. As a rule, the follicle does not burst, but the ovum is destroyed.

Stromal hemorrhage may cause so small an extravasation of blood that it can only be seen with the microscope, but it may impart a reddish color to the ovary, and even show as minute red points on the cut surface. On the other hand, it may gradually, by repeated new escapes of blood, destroy the whole tissue of the ovary, and form a hematoma as large as a man's fist or a child's head. In other cases the tissue is