rupture to any violent traction; and the shreds of the organ being mingled with pus and peritoneal effusion, have, no doubt, been described as the result of gangrene by the older authors. In these cases, the ovarian rupture was the cause of the fatal peritonitis. Another important pathological distinction between puerperal and idiopathic ovaritis is, that in the latter the adjacent peritoneum is frequently not extensively inflamed, and may for years form an efficacious boundary to inflammatory action; but in the puerperal variety, the ovarian peritoneum soon participates in, and often originates, the disease a disease which is the natural sequence of the high susceptibility to morbid action brought on by parturition, and of the increased flow, to the pelvic organs, of blood containing a greater proportion of fibrine than usual. With respect to the comparative frequency of the varieties of puerperal pelvic abscesses, I can only mention that Marchal de Calvi, having collected at random sixteen cases in which the nature of the disease was ascertained by post-mortem examination, found that there had been

The frequency of inflammatory lesions of the Fallopian tubes is much greater than is generally believed. It has been overlooked in many pathological problems of which it forms an element. This frequency is confirmed by the testimony of Drs. Ashwell and Cruveilhier; and Dr. Hooper, in the few pages prefacing his admirable delineations of uterine and ovarian disease, says that "the Fallopian tubes are frequently found to have suffered from inflammation." Their inflammation is almost always a consequence of ovaritis or metritis, and is confounded with these diseases exactly in the same way as Fallopian cysts are confounded with ovarian-a confusion of diseases which, as the same treatment is required in both cases, is indeed of but little consequence. As regards the morbid conditions which have been noticed, the fimbriae may be

found preternaturally florid, highly vascular, filled with blood, attached by recent false membranes to the ovaries or adjacent organs, or bound down to the same by firm, thick bands of long standing. The Fallopian tube is sometimes much hypertrophied under the influence of inflammation. Meigs once found it much larger than a stout man's thumb, and the finger could freely move in its canal. The fimbria of both Fallopian tubes may be destroyed, but in general those only of one or the other are totally wanting. This is a lesion of very frequent occurrence, generally coinciding with the obliteration of that extremity of the tube by which it communicates with the peritoneal cavity. The oviducts then terminate in a cul-de-sac, increase in size, become tortuous, or assume a pyriform shape, their walls being thicker than usual, and fluctuating when pressed. On being opened, they are found to contain a serous, albuminous, puriform, or bloody fluid, and their internal surface is covered with tenacious or flocculent albuminous substance, the removal of which exposes tissues which are inflamed and softened. I may here observe, that however frequently obliterations of the Fallopian tubes have been found, their imperforation, whether congenital or accidental, has been very seldom met with. A web of false membranes has been often discovered lining the interior of the oviducts of prostitutes, and of those women who have recovered from puerperal metro-peritonitis; whereas the same tubes are often found full of mucus, or even pus, in those who have died in the acute stage of that disease. In some cases, the internal surface of the oviducts is perfectly healthy, and still they are unable to perform their allotted task, owing to the existence of false membranes, which glue them to the neighbouring viscera, so as to preclude the possibility of their precise adaptation to the ovaries. Varying in density, from that of the finest diaphanous film to that of strong ligamentous bands, these false membranes are of frequent occurrence; and, in prostitutes, if we may rely on the testimony of Walker, Renaudin, and Dr. Oidham, the ovaries and Fallopian tubes are seldom found without some one or other of the lesions already described.

CHAPTER XXXI.

CAUSES AND SYMPTOMS OF ACUTE OVARITIS.

THE causes of the idiopathic and puerperal varieties have been so carefully investigated when treating of sub-acute ovaritis, that I need not again dwell on them, but content myself with observing, that acute ovaritis is produced by the great intensity or continuity of action of the causes of the sub-acute form, by the great liability of chronic ovaritis to become acute from trifling causes, the application of caustic to the neck of the womb, and instrumental interference.

While contending that, in some cases, puerperal pelvic abscesses originate in ovarian inflammation, it would be absurd to attribute them to that cause alone, for the crushing of the pelvic cellular tissue by the child's head, or by instruments, is quite a sufficient cause for suppurative inflammation in the puerperal state. I refer the reader to the chapter on the causes of sub-acute ovaritis, observing, however, that out of my twenty-six cases of idiopathic ovarian abscess, twenty were married or lived connubially, five of the twenty were prostitutes, that all the patients belonged to the reproductive periods of life, eleven being under twenty-five; that the menstrual flow had been for some months more painful in two, more irregular in eleven, and absent in three out of the twenty-six; that the disease originated during menstruation in six cases, and in three under the sudden influence of cold. Once it began soon after a kick on the groin, once after a fall downstairs on the subsidence of the menstrual flow. four cases it was the immediate consequence of marriage, and in three out of the twenty-six the ovarian abscess seemed to arise in chronic uterine inflammation. Gonorrhoea was the cause in seven cases, in one of which the disease could be traced to cohabitation at a menstrual period; in two to the suppression of the discharge, one woman suddenly suppressing

In

the gonorrhoeal flow by astringent injections, the other by taking a full dose of copaiba.

Ovaritis has this in common with orchitis, that occasionally both may occur in connexion with variola. Dr. Beraud has published-Archives Générales de Médecine, Vol. XIII.three cases, in which, on a post-mortem examination, pus was found in the ovary of a woman who died of variola. Dr. Druitt has seen a case of ovarian abscess for which he could find no other cause than the use of sinapisms to the breasts, to promote the secretion of milk.

SYMPTOMS OF ACUTE OVARITIS.

LOCAL SYMPTOMS.-Pain is one of the first indications of acute ovaritis. This is increased by all movements of the body, particularly by extending the limb of the side affected, but this is common to many varieties of pelvic tumours. The pain varies in intensity, being bearable, or acute. Dr. Ashwell mentions a case where it was so overwhelming, that syncope was induced by the patient's rising in bed to relieve the bladder. The nature of the pain varies, being heavy, dragging, throbbing, or accompanied by a feeling as if a foreign body were boring its way through the vulva. When alarmed by the pain, if one examines the ovarian region, which is its seat, a tumour is sometimes seen distinctly pointing from the side of the pelvis, but one cannot from its absence infer the non-existence of ovarian inflammation, for the enlarged ovary, if free from adhesions, often dips down into the recto-vaginal cul-de-sac. The hand detects an increase in the natural heat of the pelvis, of which the patient herself is frequently aware, and pressure increases the pain; there may be also a sense of uneasiness or numbness in the limb corresponding to the seat of the tumour, as in iliac abscess.

By a vaginal exploration this passage will be found hotter than usual, and not lubricated by mucus. Ovarian abscesses, like other pelvic tumours and incipient ovarian cysts, interfere with the same organs, and produce the same local symptoms. The physical means of examination which apply to pelvic tumours, also relate to the detection of ovarian dropsy in its early stage. When the tumour is small, it

may subside between the uterus and the rectum, or between the former organ and the bladder, and in some rare cases, it may not only press on these organs, but actually force down the fundus uteri, causing its prolapsus. If the tumour develope itself behind the uterus, it may press it against and above the pubis, thus producing abnormal deviations by its continued pressure. When the tumour has increased, and is no longer entirely in the vicinity of the vagina, having ascended towards the brim of the pelvis, valuable information respecting its position and nature may be afforded by the finger, though it cannot reach the seat of disease. Thus the tumour may depress the uterus to the right or to the left, or may flatten it against the pubis, causing its complete anteversion, and rendering it impossible for the finger to attain the os uteri. M. Robert of Paris has met with several cases of this description. This cannot take place without elongating the vagina and urethra, altering their form, and interfering with their functions, rendering micturition difficult; and there are patients who can only pass water on reclining their body as much backward as possible. Boivin and Laugier have found it necessary to depress the tumour, in order to pass the catheter; in other cases, a male catheter only can penetrate the bladder; it is sometimes impossible to introduce even this instrument. When one can only just feel the inferior segment of the uterus, its usual mobility may be found checked, or it may be so bound down by false membranes, the result of peritonitis, that it is rendered immoveable. A rectal examination confirms the conclusions of the previous inquiry; and as the double-touch affords a means of establishing an accurate diagnosis of these difficult cases, one can thus guard against mistaking the uterus for an ovarian tumour. When the tumours are small, they are sometimes found in the recto-vaginal space; and, if their contents be liquid, fluctuation can be detected.

In the commencement of acute ovaritis, the dysuria is only sympathetic; but, when the tumour has increased in size, should it fall between the bladder and the uterus, it may give rise, as in the incipient stage of ovarian cysts, to the desire of passing water every minute. If the ovarian tumour becomes still larger, and encroaches on the pelvic cavity, the