preserved, but so infiltrated with blood that the whole ovary is like a sponge soaked in blood. Such enlarged ovaries are bound by adhesions to the neighboring organs. The stromal hemorrhage may be primary or follow as a secondary event after follicular apoplexy.

Hematoma of Ovary (a little less than natural size): a, follicular hematoma, 12 millimeters in diameter, inner measure; fresh blood-clot easily separated from the surrounding wall, situated in the outer end of the ovary, one-half of it touching the stroma, the other half covered with a layer varying from 2 to 3 millimeters in thickness, without any opening; bb, dilated follicles with serous contents; c, Fallopian tube.1

Any extensive hemorrhage may cause rupture of the ovary, the blood pouring into the peritoneal cavity or penetrating between the two layers of the broad ligament. The extravasated blood undergoes changes similar to those just described for the follicular form.

Etiology.-Hyperemia and hematoma of the ovary may be due to any thing that causes venous stasis, such as masturbation or venereal excesses, heart disease, pulmonary phthisis, cerebral apoplexy, tumors, adhesions compressing the veins, or torsion of the ala vespertilionis. Secondly, they may be referable to dissolution of the blood, such as occurs in severe burns, phosphorus-poisoning, typhoid fever, puerperal septicemia, scurvy, etc.

Left ovary from my salpingo-oophorectomy on Mrs. Pin St. Mark's Hospital, Nov. 29, 1892. The right ovary contained a serous cyst measuring 2 cm. in diameter.

Thirdly, hematoma may be developed from gyroma,' which is the same as corpus albicans (p. 74), and may be the terminal stage of a corpus luteum, or under influence of chronic oöphoritis may represent the first stage of an endothelioma, an abnormal formation, which will be described under Oöphoritis. Gyroma may occasionally lead to the formation of a hematoma, and endothelioma does so quite frequently. Symptoms.-A patient affected with hyperemia of the ovary is liable to suffer from menorrhagia. At the time of menstruation she is seized with sudden pain in the region of the ovaries, extending down the thighs, and sometimes accompanied by neuralgia of the breasts. She has no fever.

Hemorrhage in the ovary may take place without giving rise to symptoms. If the collection is large, it causes pain, nausea, vomiting, and the ovary is felt to be enlarged. If rupture occurs, the usual symptoms of internal hemorrhage are present, such as shock, pallor, abdominal pain, a cold clammy skin, and a weak, rapid pulse. If a large hematocele is formed, a fluctuating swelling can be felt through the abdominal wall and the vagina.

Diagnosis.-Hyperemia or apoplexy may be diagnosticated, if in a healthy person one or both ovaries suddenly become enlarged and tender without fever. In a patient affected with blood-dissolution the apoplexy may be inferred, if she suddenly is seized with ovarian pain, and a movable tumor can be felt in the pelvis.

A periodical increase of suffering at the time of menstruation in a person with diseased ovaries is a sign of congestion.

The sudden appearance of the signs of internal hemorrhage in such a person denotes that rupture of the ovary has taken place.

An extravasation of blood into the broad ligament does not extend so high up as the tumor formed by intraperitoneal hemorrhage; indeed, it often forms a tumor at the base of the broad ligament.

the

A swollen Fallopian tube often is more sausage-shaped, whereas Ovary is more round.

Sometimes an aspirating needle may be thrust in through the vaginal roof, and the bloody fluid will then help to establish a diagnosis. Prognosis. Hyperemia can, as a rule, be cured. Hematoma may also be absorbed, but occasionally a rupture occurs, which may end fatally. If due to endothelioma, the whole constitution suffers, and grave nervous symptoms are developed. The normal ovarian tissue disappears gradually, and the ova are destroyed.

Treatment.-In hyperemia, rest, inclusive of physiological rest—

1 This subject was first treated by Dr. Mary Dixon Jones, and later by Dr. Francis Foerster and Dr. H. J. Boldt, all working under the egis of Dr. C. Heitzmann: Jones, N. Y. Med. Jour., Sept. 28, 1889. May 10-17, 1890; Times and Register, Apr. 30, 1892; Foerster, Amer. Jour. Obst., May, 1892, vol. xxv. p. 577; Boldt, International Med. Congress, Berlin, 1890, and Deutsche med. Wochenschr.,

that is to say, abstinence from sexual excitement-is of great import

ance.

The general health should be improved by means of hygienic measures and tonics (p. 225). The nervous system may be quieted by the use of bromides. A derivation to the skin by means of blisters may be useful. The bowels should be kept open. In girls of ardent temperament or with bad habits marriage may answer a good purpose. The usual treatment for pelvic inflammation, such as the use of hot douches, painting with tincture of iodine, tampons with ichthyol-glycerin or plain glycerin, or the galvanic current, should be instituted. If there is an acute attack, the patient should stay in bed, have an ice-bag on the hypogastric region, and be given morphine enough to combat pain. If the ovaries have suffered much in their structure, it may even become necessary to remove them. When symptoms of rupture are present, laparotomy should be performed at once, and the ovary from which the hemorrhage comes should be extirpated together with its tube. The other ovary should be left, if it is not seriously diseased.

CHAPTER IV.

OÖPHORITIS.

OÖPHORITIS, the inflammation of the ovary, may be acute or chronic.

A. Acute Oöphoritis and Ovarian Abscess.

The inflammation may begin on the surface,-perioöphoritis,—which is identical with local peritonitis (although the ovary has no peritoneal covering, p. 65), in the follicles, follicular oöphoritis,-or in the stroma,-interfollicular oöphoritis,-just as we have seen in regard to hemorrhage, with which it is in many cases connected in such a way that it is difficult to say which has preceded the other. The distinctive anatomical feature is here, as in the inflammation of other parts of the body, the infiltration of the tissue with small round cells, and, if suppuration supervenes, the presence of pus-corpuscles. To the naked eye the condition is in the beginning much like hyperemia; the ovary is enlarged and impregnated with a reddish fluid; later yellow points and streaks appear; and finally these melt together, and an abscess is formed. Of these there may be one or more. puerperal and gonorrheal cases usually both sides are affected; in others, as a rule, only one ovary is inflamed.

In

Before pus is formed the inflammation may end in resolution, but the ovary rarely returns completely to its pristine condition. As a rule, it remains enlarged by formation of new connective tissue or becomes smaller by subsequent cicatricial retraction—cirrhosis.

The ovum and the epithelium of the follicles undergo fatty degeneration. Sometimes they are transformed into small cysts with thickened walls, or they are destroyed, leaving a cicatrix. An abscess may destroy the whole ovary. As a rule, plastic lymph is thrown out as a superficial covering over the abscess in the depth of the ovary, and thus the organism is protected, but rupture may take place into the peritoneal cavity and cause general peritonitis. The pus in an ovarian abscess may be "laudable" or have an offensive odor due to absorption of gas from the rectum. It may become inspissated, and finally form an innocuous calcareous mass.

Etiology.-Extensive oöphoritis is a rare disease outside of the puerperal state. It may be primary or secondary. The primary may be caused by hyperemia and hematoma of the ovary (p. 554), by sexual excesses, or by sudden suppression of the menstrual flow (pp. 129, 238). It may also appear as part of a constitutional disease, such as the eruptive fevers, cholera, septicemia-whether puerperal or not-and poisoning with phosphorus or arsenic. It may follow minor operations, such as the use of the sound, the incision of the cervix, trachelorrhaphy, etc. The common course is that the inflammation first attacks the endometrium, then the tubes, and finally extends to the ovary; but it may also reach the ovaries directly through the lymphatics.

An ovarian abscess may even be due to a needle finding its way from the intestine into the ovary.1

Secondary oöphoritis may also follow after peritonitis, and most frequently it is due to gonorrheal infection, which latter works its way up from the vagina through the uterus and tubes.

Symptoms. In most cases the symptoms are obscured by those of the accompanying disease, especially salpingitis or peritonitis. But sometimes it is possible to feel the ovary to be enlarged. It is the seat of a burning pain, radiating down to the knee, to the bladder, and the rectum, and it is exceedingly tender to the touch. The knee on the affected side is sometimes drawn up; occasionally there is a reflex pain in the breast, and nearly always nausea. Like orchitis in the male, oöphoritis may alternate with mumps.

An ovarian abscess gives rise to recurrent attacks of chills and fever. Sometimes the swollen ovary can be felt, and perhaps even fluctuation can be made out. The abscess may open into the peritoneal cavity, the intestine, especially the sigmoid flexure, the bladder, less frequently into the vagina, and rarely even through the abdominal wall.

1

1 Frank W. Haviland, New York Med. Record, Oct. 2, 1892, vol. xlii. p. 398.

Diagnosis. It is seldom possible to make an entirely sure diagnosis. This can only be done if we feel the enlarged and tender evary. In a suppurating ovarian cyst the symptoms are less acute. Salpingitis and pyosalpinx are sausage-shaped, the inflamed ovary and ovarian abscess globular. Pelvic abscess is situated lower down and absolutely immovable, while the ovarian abscess may be more or less movable.

Prognosis. The prognosis in the common non-septic, acute oöphoritis is, upon the whole, favorable as to life, even if the disease rarely ends in complete resolution. The inflammation may subside in four or five days. The septic form is apt to form an abscess, and it is not rare that the abscess bursts into the abdominal cavity and causes death from septic peritonitis. If the abscess opens into the gut, the opening may close speedily, but sometimes a fistulous communication remains, which may give rise to exhausting fever. Since we have seen that the ova are liable to degenerate, we can understand that oöphoritis often leads to sterility. One attack is frequently followed by others, so-called chronic oöphoritis.

Treatment. The patient must be kept quiet in bed. An ice-bag is applied over the affected part (p. 187). The bowels should be kept open with saline aperients (p. 225). Pain is to be combated with opiates, preferably hypodermic injections of morphine.

If the symptoms indicate the presence of an abscess, the ovary should be removed, either by abdominal or vaginal section. Even if the ovary is adherent, the adhesions are fresh and can in all likelihood be separated. Some prefer, however, under these circumstances, if the ovary is within easy reach, to aspirate, make an incision, and drain from the vagina.

B. Chronic Oöphoritis.

By chronic oöphoritis is understood a chronic condition characterized by the remains of acute inflammation of and in contact with the ovary, congestion, and repeated attacks of acute inflam

mation.

mass.

Pathological Anatomy.-In most cases the ovary is enlarged to two or three times its normal size, and has an oval or globular shape. In others it is smaller than normal, forming an irregular shriveled Very frequently it is more or less cystic (Fig. 284). The capillaries increase in size from the periphery toward the center, forming a structure like that of erectile bodies. The anastomosis between the ovarian and the uterine artery is dilated, which may explain the endometritis so often found combined with chronic oöphoritis. The ovisacs and the ova are often diseased or disappear. First medullary corpuscles are developed, and the yolk and the germinative vesicle