pecially the ovaries) stimulate the brain to a higher development. A very large part of the brain and nerve power is devoted to reproduction, and if that function is never established because of the absence of the ovaries, the brain and nervous system are never fully developed. When a woman is deprived of the sexual organs the nutritive system may possibly attain a normal development, but the nervous system does not-it remains upon a lower plane. There is usually mental weakness and often derangement of mind among those in whom the ovaries are imperfectly developed. Among sixteen young single women, that came under my observation in the Insane Asylum, I found twelve who had imperfectly developed sexual organs. Some of them had never menstruated at all, and others had done so imperfectly. The history of these cases led to the conclusion that the defective development of the ovaries was an important element in causing insanity. They no doubt inherited an insane neurosis or diathesis, but the absence of ovarian influence, which favors a higher and more complete development of the nervecenters, acted as the major-cause in producing the insanity. This is not claimed to be a positively correct deduction, but there is certainly strong presumptive evidence that such was the case. The mental derangement appeared in the majority of them at or about the period of puberty. There was nothing in the size or development of these patients to indicate any marked defect in the nutritive system. The nervous and sexual system alone were deficient. They appeared to have passed through girlhood in a normal way (although not manifesting a high order of mental capacity) until the period when the sexual organs should have begun to exercise their influence in completing the higher development of the nervecenters. When that failed to take place, the brain became deranged, instead of assuming new activities. Still it is possible that the imperfectly developed sexual organs resulted from inferior general organizations which were from the beginning of a low type, and that the insanity which followed was due to transmitted lesions, and was not dependent upon the sexual organs at all. However, the facts appear to favor the opposite conclusion. One thing is certain regarding this subject: there is enough in the nature of the cases mentioned to invite further investigation in order to settle, as far as possible, the relation of the ovaries to insanity and other diseases of the nervous system which occur at puberty.

As the period of puberty approaches a considerable number of Graafian follicles (from twelve to thirty) enlarge, the largest reaching a diameter of half an inch. In the early stage of development,

it will be remembered, the smallest follicles were found in the cortical layer, those of medium size in the middle layer, and still deeper, the larger follicles. These follicles increase in size by the production of an increased amount of liquor folliculi. This so distends the wall of the follicle as to cause it to project from the surface of the ovary, and to become thinner and thinner until finally it bursts, discharging the ovum with some of the cells of the membrana granulosa, especially those forming the cumulus proligerus. The ovum passes into the Fallopian tube, and through it descends to the uterus. This ripening and discharge of ova is the process of ovulation and occurs periodically, in the human female about every four weeks. As the time approaches in each month for the rupture of a follicle there is an abundant formation of vascular loops in connection with increased growth of the membrana propria, which together with the liquor folliculi distends the wall of the follicle. This distention stimulates the ovarian nerves, and as a result there is an increased flow of blood to the ovaries and other organs of generation. The wall of the follicle, in addition to being distended, also becomes fatty at its most projecting part, and when it is no longer able to withstand the internal pressure it bursts and the ovum is discharged. When this rupture takes place there is in the human female hæmorrhage from the vessels already spoken of as being found in the interior of the follicle. The amount of blood effused is sufficient to fill the cavity of the follicle. It soon coagulates, the serum is reabsorbed, the hæmoglobin becomes hæmatoidin, and after a time the coloring-matter disappears. In short, the same changes, take place in the blood here as when a hæmorrhage occurs elsewhere in a closed cavity. The wall of the follicle becomes hypertrophied and convoluted, and later on undergoes fatty degeneration, with the formation of lutein, giving to the structure a yellow color, on which account it has been called a corpus luteum. The corpus luteum spurium by which name the corpus luteum of menstruation is known, reaches its maximum of development at the end of the third week after menstruation, at which time it commences to diminish in size until at the end of the eighth week it is reduced to an insignificant yellowish cicatrix about one fourth of an inch in diameter, but it sometimes may be discovered if carefully sought at the end of eight months. If, however, the ovum which escaped from a given Graafian follicle becomes impregnated, then the process becomes modified in that follicle. The corpus luteum is then denominated verum instead of spurium. The differences between the two varieties of corpora lutea are of degree not of kind. The changes which take place are

the same in both up to the end of the third week, then, instead of diminishing, the corpus luteum verum continues to grow until the end of the fourth month when it reaches the height of its development. It retains this maximum until the beginning of the seventh month when it commences to diminish, but may sometimes still be discovered nine months after delivery. The history of the corpus luteum is admirably described by Dalton to whose work on human physiology the reader is referred for a detailed account of its formation, and the subsequent changes which it undergoes.

LESIONS OF FORMATION OF THE OVARIES.

Both ovaries may be entirely absent, or, perhaps, it would be more correct to say, entirely rudimentary, or one may exist alone, or there may be a third one present. When a single ovary is absent the condition of uterus unicornis usually exists, although this malformation of the uterus is not necessarily accompanied by an absence of either ovary.

The absence of an ovary may be accounted for in different ways; it may not have been developed, it may have been properly formed, and by some dislocation of the uterus have had its circulation and nutrition so interfered with as to have caused it to shrivel and become absorbed, or it may have become attached to some other abdominal organ, and then its absence be only apparent and not real.

Several cases are on record in which a third ovary has been found. The most interesting of these is one which is described and figured by Winckel in his work on "Diseases of Women." In most of the instances the supernumerary ovary was found near one or the other of the normal ovaries, and either behind or in the broad ligament. In Winckel's case it was situated in front of the uterus and connected with the posterior wall of the bladder.

As Winckel has so well pointed out, these cases of supernumerary ovaries are always to be borne in mind in making a diagnosis. A cyst forming in the third ovary as found in his case might be detected between the bladder and the uterus, and be mistaken for some other form of tumor. In such cases also the removal of two ovaries may not prevent conception, the third ovary being in all respects normal, and consequently able to discharge ova. So also even after two ovaries are removed, should a third exist a cystoma may form, which will require operative interference.

CHAPTER XXV.

DISEASES OF THE OVARIES. (CONTINUED.)

HYPERÆMIA, ACUTE AND CHRONIC OVARITIS AND PROLAPSUS OF THE OVARIES.

Inflammation of the Ovaries.-There are two forms of inflammation of the ovaries, the acute and the chronic. These are very distinctly different so far as their clinical history is concerned. There is another affection closely allied to these which is described by some writers as hyperæmia. All these are, however, but different degrees of the same affection, though each follows a different course and gives a history peculiar to itself. This latter fact justifies the consideration of the acute and chronic forms, at least, of ovaritis as separate affections. The third form, hyperæmia, is not so fully understood nor does it stand out so distinctly from the chronic form as to make its description easy.

Ovarian Hyperæmia.-While many of the characteristics of ovarian hyperæmia are like those of ovaritis, there is very good reason based upon clinical evidence, to believe that the two are different both in pathology and clinical history.

Ovarian hyperæmia, as it is generally observed, resembles many of the so-called functional diseases of the ovary, in that there is derangement of function, with symptoms of organic disease which usually disappear, leaving no evidence that there has ever been any charge of stricture or any products of inflammation. All this demonstrates that the pathology is, as the name implies, a derangement of circulation in which there is congestion, and the consequent derangement of function with the accompanying or resulting pain and suffering. The hyperæmia usually affects both ovaries, and, as a rule, extends to the other pelvic organs, after a time, at least. The derangement of function also extends to the uterus giving rise to derangement of menstruation. In fact, the congestion and func

tional derangements of the uterus are secondary to the ovarian hyperæmia. There is much in regard to pathology of this affection which is inferred from the symptoms, and can not be demonstrated by post-mortem investigation. The congestion may be of long or of short duration, its continuance depending upon the persistence of the causes which give rise to it. If it is well-marked and longcontinued, it tends to chronic ovaritis, and, perhaps, to degeneration of the ovaries and premature atrophy. Should the causes which produce the congestion continue active and no treatment be employed, the affection may continue indefinitely. The general health becomes undermined by the derangement of the menstrual function and the exhaustion of the nervous system; and if the patient is not relieved by treatment or by improved hygienic conditions, she continues a sufferer until the menopause.

With so little that is definite regarding the pathology, one might well ask if the fact is yet established that there is a distinct affection to be known as ovarian hyperæmia. In answer to this, it can only be said that the clinical history clearly points to this derangement of the circulation as the only rational explanation of the phenomena presented in these cases. It should be stated here that there necessarily must be present in this affection a derangement of ovarian innervation as well as hyperæmia. In fact, it appears that this derangement is the starting-point in the morbid condition. This view of the matter is favored by the affection depending for its origin upon perversion of the emotions in those of nervous tempera

ment.

Symptomatology.-Hyperæmia of the ovaries occurs most frequently among those who are unmarried, or among young widows who have never had children.

It does not come on abruptly like an attack of acute ovaritis, as a rule, though it occasionally does so, but is developed rather gradually. Those most liable to this affection are the nervous and emotional who live in conditions of life favoring excitation without complete functional action of the sexual organs. I have never seen

a case of this kind among those who lived under wholesome conditions of life or who were married, bearing and nursing children, and who lived quiet, rational lives. At the beginning there are pain and heaviness in the region of the ovaries, usually accompanied by much nervous disturbance of the nature of irritability and weakness, the patient being easily excited and as easily fatigued. Soon after the appearance of these symptoms the menstrual function becomes deranged. There is usually menorrhagia, which is