cannot be controlled, as in the earlier months, by ligation of the ovarian and uterine arteries. The result in these cases is determined by the ability of the operator. A full-term living child, the whole sac, and the placenta have been successfully removed. If the attachments are such that the surgeon considers it unsafe to attempt the removal of the sac and the placenta, the sac should be incised and the fetus should be removed, the cord being divided between two ligatures; the sac should be sutured to the abdominal incision; the cord should be drawn through the opening, and the sac packed with gauze. At the end of four or five days the gauze pack may be removed, under anesthesia if necessary, and the placenta may be taken away. There is very much less risk of hemorrhage after the lapse of a few days. Some operators prefer to allow the placenta to come away spontaneously. This is sometimes necessary.

It will be seen, from this consideration, that the treatment of all varieties of ectopic gestation is operative, and that the sooner the operation is performed the better for the patient. Consideration for the life of the child should have no influence in determining the time of operation.

21

CHAPTER XXVII.

DISEASES OF THE OVARIES.

Anatomy. The ovaries vary a good deal in size, within the limits of health, in different individuals. It is unusual to find the two ovaries in the same person exactly alike in size, shape, and appearance.

Convoluted
Tube

The size, shape, and appearance of the ovary change at the different periods of life. In the new-born child the ovary is elongated and lies parallel to the Fallopian tube (Fig. 155). In rare cases this infantile shape of the ovary may persist throughout life.

Uterus, tube, and ovary of a child one month old Sadon'

The general shape of the mature ovary is oval. The

average measurements are

long axis 3 to 5 centimeters; breadth, 2 to 3 centimeters; thickness 12 millimeters; weight, 100 grains These measurements are subject to great variations. Henning's table of measurements shows that the ovary of the multipara is no larger than that of the virgin.

Ater the menopause the evanes shrink a great deal in se Sharing in the general atrophy of all the reproduc The ovary of an o'd woman may weigh but

scars which in time cover and render irregular the whole surface of the ovary (Fig. 156).

The surface of the ovary becomes more irregular and wrinkled after the menopause. The follicles disappear, until finally nothing is left but a mass of fibrous tissue and a few blood-vessels.

The ovary lies in the posterior layer of the broad ligaIt is attached by this connection with the broad

ment.

FIG. 156. Ovary (natural size), with the Fallopian tube in relative position (Sutton).

ments.

The ovarian ligament extends from the inner end of the ovary to the angle of the uterus immediately below the origin of the Fallopian tube. This ligament varies in length from 3 to 5 centimeters. It is shortest in the virgin, and longest in the multiparous woman. The ligament consists of a fold of peritoneum containing unstriped muscular fiber from the uterus.

The infundibulo-pelvic ligament is that part of the

It

upper margin of the broad ligament lying between the distal end of the Fallopian tube and the pelvic wall. is about 2 centimeters in length. The length is greatest in the multiparous woman.

The position of the ovary is maintained by its attachments and by its own specific gravity. The considerations that have been discussed in regard to the position of the uterus also apply here.

The blood-vessels are the utero-ovarian arteries and the ovarian arteries and veins. The ovarian artery is homol

FIG. 157.-View of the posterior surface of the uterus, Fallopian tubes, ovaries, and broad ligaments. The infundibulo-pelvic ligament is shown on the left (Dickinson).

ogous to the spermatic artery in the male. The course of the ovarian veins has an important influence upon some pathological conditions of the ovaries.

The right ovarian vein enters the inferior vena cava at an acute angle, and at the junction of the two there is a very perfect valve.

The left ovarian vein enters the left renal vein at a right angle: there is no valve on this side. This anatomical difference affords a probable explanation of the greater tendency to congestion and prolapse of the left

Ovary.

The ovary is composed of connective tissue which surrounds the Graafian follicles, blood-vessels, lymphatics, nerves, and unstriped muscular fibers. The posterior portion, or the free portion of the ovary, is covered with the germinal epithelium, or modified peritoneum, which is continuous with the peritoneum of the broad liga

ment.

The ovary is divided into two portions, which present distinct anatomical, physiological, and pathological differences.

The oophoron is the egg-bearing portion of the ovary. It corresponds to the free border of the gland.

The paroöphoron corresponds to the hilum of the ovary -that portion in relation with the broad ligament. The paroöphoron contains no ovarian follicles. It is composed of connective tissue and numerous blood-vessels. In the paroöphoron of young ovaries remnants of gland-tubules-vestiges of the Wolffian body-may be

found.

Accessory ovaries have been described by several writers, and their existence has often been assumed to account for the persistence of menstruation after a supposed complete salpingo-oophorectomy. It is very doubtful if a true accessory ovary has ever been found. Bland Sutton says: "As the evidence at present stands, an accessory ovary quite separate from the main gland, so as to form a distinct organ, has yet to be described by a competent observer." It is probable that the bodies that have been described as accessory ovaries have been more or less detached portions of a lobulated ovary, or small fibro-myomatous tumors of the ovarian ligament. Abdominal surgeons have had opportunity of examining thousands of ovaries at operation, and yet I know of no one who has come across a third ovary.