phatics, cancerous epithelial cells being carried into these vessels, in

which they cause thrombosis and infection of the surrounding tissue. Like other tumors, carcinoma of the ovary may undergo secondary

Patient with Carcinoma of Ovary, Ascites, Anasarca, and Marasmus.

changes, especially fatty degeneration, which leads to the formation

1 Photograph of specimen from my operation on Mrs. L., in St. Mark's Hospital, on April 12, 1894.

2 This is proved by actual observation of microscopical specimens from a carcinomatous tumor of the pelvic floor and the ovaries belonging to it, by M. Dixon Jones, Med. Record, March 11, 1893, vol. xliii. No. 10, p. 295, et seq.

of cystic cavities with ragged walls of carcinomatous tissue-a condition called cystocarcinoma.

Etiology.-Carcinoma rarely attacks the healthy ovary, while, as we have seen, it often occurs in ovarian cystomas. Its cause is unknown. It is found in young women, and even in children, most commonly near the two ends of menstrual activity, puberty or the

menopause.

Symptoms.-The disease may begin as an acute inflammation or develop gradually. It is characterized by amenorrhea, pain, rapid growth, local peritonitis, ascites, edema of the thighs, and general marasmus (Fig. 329).

Diagnosis. It is distinguished from fibroid and sarcomatous tumors by the unusually rapid development, greater pain, edema of the thighs, and the presence of tumors in Douglas's pouch, the lumbar region, the omentum, stomach, liver, or spleen.

The ascitic fluid accompanying malignant ovarian tumors (carcinoma, sarcoma, or papilloma), obtained by aspiration, contains sometimes large round or pear-shaped cells, with a large nucleus, either isolated or in groups. Much more conclusive than aspiration is, however, exploratory incision, which enables us to feel the nodules on the tumor, and perhaps on other parts, and to judge whether an extirpation should be attempted or not.

Treatment. If performed early, ovariotomy may effect a radical cure. If the neighboring organs are implicated, it may yet give relief from painful tension for several months. But if other tumors are felt beside the ovary, the operation is contraindicated.

VI. Tuberculosis.

Next to the tubes and the uterus, the ovary is the part of the genital tract most commonly affected by tuberculosis. It may be primary or secondary. It may be part of general tuberculosis, and is then brought to the ovary through the blood, but it may also reach the ovary through the genital canal.

Pathological Anatomy.-Miliary tubercles are rarely found. The affection may be limited to the surface or invade the whole organ. The ovary is then somewhat enlarged, soft, and contains cheesy deposits ranging in size from that of a millet-seed to that of a marble. These tuberculous nodules may soften and rupture into the peritoneal cavity, causing peritonitis. The surface of the ovary is commonly covered with layers of inflammatory exudation and adhesions. Symptoms.-The symptoms are those of chronic oöphoritis.

Diagnosis. The disease can only be diagnosticated, if swelling of 1 Garrigues, Diagnosis of Ovarian Cysts, pp. 94-97.

Dr. G. M. Tuttle of New York has reported a case of apparently primary tuberculosis of the ovary in Amer. Jour. Obst., Jan., 1890, xxiii. p. 68.

the ovary is combined with pulmonary tuberculosis or local tuberculosis of the visible part of the genital canal, or if the discharge from the uterus contains cheesy masses and tubercle-bacilli.

Treatment. If the affection is primary, salpingo-oophorectomy may lead to a cure. If it is combined with pulmonary tuberculosis, and the disease has been checked in the lungs, the removal of the appendages is still indicated. If it is allied to a similar affection of the tube and the uterus, hysterectomy may be added (p. 491). Even tubercular peritonitis may be cured by the operation. On the other hand, the operation is contra-indicated as long as the disease spreads in the lungs. If no radical cure is possible, the usual medical and hygienic treatment is all we have to rely on.

CHAPTER VI.

OÖPHORALGIA.

THE Ovary may be the seat of neuralgia.

In most cases this forms only part of hysteria, but the discase may be found in women who show no other symptoms of that affection. It may be of malarial origin.

The left ovary is affected much more frequently than the right, for which circumstance we may, perhaps, find an explanation in its contact with the rectum, the contents of which are apt to press on the ovary on this side, or the different disposition and construction of the ovarian vein on this side (p. 74). Sometimes the affection is bilateral. The pain is spontaneous, or may be produced by pressure on the ovary. It is felt in the hip, shooting back to the lumbar region or down the leg, and is so severe that the patient can neither be moved nor stand. Very often it is combined with hemianæsthesia of the corresponding side and hystero-epileptic seizures. Pressure on the ovary produces, first, cardialgia and vomiting; next, palpitations, with frequent pulse and globus hystericus; and, finally, often a hissing sound in the corresponding ear, pain in the temple, darkening of the eyesight, loss of consciousness, and convulsions.

While pressure on the ovary may produce such an attack, it can also check a spontaneous one.

Diagnosis. In chronic oöphoritis the ovary is enlarged, and often uneven and fastened by adhesions.

Treatment. The treatment consists in rest, anodynes, galvanism, faradization with the secondary current of high tension (p. 230), and tonic and antihysteric remedies. If the disease is malarial, it yields to large doses of quinine.' Oophorectomy has sometimes a marked beneficial effect, but is in many cases fruitless.

1 Case of H. C. Coe, Amer. Jour. Med. Sci., April, 1891, vol. ci. p. 365.

PART VII.

DISEASES OF THE PELVIS.

UNDER this title we describe the affections of the peritoneum, the connective tissue, and the blood- and lymph-vessels of the true pelvis, including the ligaments of the uterus.

CHAPTER I.

MALFORMATIONS.

IN speaking of the uterus (p. 394) we have mentioned that lateroposition is due to an uneven development of the two broad ligaments, anteposition to defective development of the parts situated in front of the uterus, and retroposition to a similar defect in those behind it. Perhaps some cases of congenital anteflexion and anteversion originate in too great shortness of the round ligaments.

The peritoneal pouch, which in the fetus forms the canal of Nuck, and normally is transformed to a fibrous string, may remain open. It may either remain in connection with the abdominal cavity or be closed at the upper end and become the seat of hydrocele, or form a sheath around the round ligament, which must be pushed back in Alexander's operation (pp. 59, 262, and 449).

CHAPTER II.

ANEURYSM OF THE UTERINE ARTERY.

I AM not aware that more than one case of aneurysm of the uterine artery has been reported. Upon vaginal examination there was found a pulsating tumor in the pelvis of the size of a hazelnut, which was diminished by pressure, but refilled again each time pressure was discontinued. It gave a subjective sensation of throbbing. It was supposed to be due to the use of leeches in the vagina, and

1 Mars, Excerpta Medica. No. 2, Nov., 1891.

might, perhaps, also be due to childbirth.

The treatment recom

mended is galvanopuncture, with the positive pole in the tumor, or forcipressure.

CHAPTER III.

DISEASES OF THE BROAD LIGAMENT.

A. Varicocele of the Broad Ligament, or Parovarian Varicocele. VARICOCELE in the female corresponds to the same condition in the male, but the different anatomical relations constitute rather considerable differences between the two. While in man the veins of the testis follow an almost perpendicular course, those of the ovary are nearly horizontal. The spermatic veins soon form a single trunk, whereas the pampiniform plexus in woman communicates freely with the uterine, the vaginal, and the vesical plexus. There will, therefore, be less tendency to the disease in woman than in man. As a matter of fact, it is about three times less common in female cadavers than in male, and is rarely recognized in the living subject, although we may be sure that the swelling must have been much larger during the patient's lifetime than after death.

By varicocele we do not mean the enlargement of veins in the broad ligament which accompanies tumors, especially uterine fibroids, but an isolated swelling of the ovarian veins, implicating more or less the other veins of the broad ligament. It has been divided into superior parovarian varicocele when it is situated between the ovary and the tube, and inferior parovarian varicocele, when it is found below the ovary. It may reach the size of a hen's egg, and is composed of a conglomeration of veins, the walls of which are often thickened, and which may contain phleboliths. It is much more common on the left side, but may be found on the right or on both, the preponderance on the left side being without doubt due to the lack of a valve in the left ovarian vein, and to the fact that it opens at right angles into the renal vein (p. 74).

Etiology. The condition is probably due to subinvolution after confinement; a relaxed condition of the tissues following a low state of the general health; an original weakness of the walls of the veins; pressure from fecal accumulation in the sigmoid flexure, which lies in front of the ovarian vein; or displacements of the uterus, especially retroversion and retroflexion, which interfere with the free return of the blood through the infundibulopelvic ligament.

Symptoms.-The most prominent symptom is pain of a peculiar dull, aching character, extending up the side to the region of the kidney. The pain disappears when the patient is in the horizontal posi