Tait, and this operation has supplanted all other methods of treatment. Recently, many favorable results from its performance have been reported by Lédiard, F. A. Martin, Saenger, Tait, Thomas, Wallace and others.

b. TUBERCULOSIS OF THE TUBES.

Since it has become known that tuberculosis is caused by a specific bacillus, and is only a local inflammatory process, we no longer include this affection with the neoplasms. The bacillus has been demonstrated by Maier in the cases of tuberculosis of the tubes reported by Wiedow. Primary tuberculosis of the tube When thus affected, the tube is usually drawn down by

is rare.

Cavum corporis, cavity of the body of the uterus; linke Tube, left tube; ov. s., left ovary; rechte Tube, right tube; ov. d., right ovary.

the side of the uterus, as shown in fig. 84, and attached to it by pseudo-membrane. It is generally much thicker than normal, and as distension is hindered by the broad ligament, it becomes convoluted and shows sinuous diverticuli, as in fig. 84. Both ostia are usually closed, but the outer one is occasionally permeable, as is also the inner one at times; the tube is dilated and filled with caseous material; its walls show evidences of caseous inflammation, the epithelium having disappeared to be replaced by a layer of this substance; granulation tissue is found beneath

the latter, at times, in little masses, and this may penetrate the muscular tissue. The latter is often hypertrophied, the vessels are large and their walls thickened, the hyaline membrane very distinct. The bacilli may be readily demonstrated, lying between these elevations, by the usual methods of staining.

The tubes are always involved in tuberculosis of the genitals, and in about one-half of all cases they alone are affected. Beginning in this structure, the ravages of tuberculosis are greatest; the specimens in our possession show that the disease develops and is most severe at the outer extremity.

With regard to the frequency of tuberculosis of the tubes, I find it present in 1 per cent. of the autopsies made by me; Namias, once in every 8; Kiwisch, in every 40; Puech, in every 50; Louis, in every 66; Cless, in every 70, and A. Courty, in every 100. One of the most interesting cases I have ever seen is described on pages 409 to 413 of my Pathologie der Weibl. Sexualorgane :

The abdominal incision was already made in a case which had been diag nosticated as an ovarian tumor complicated by pelviperitonitis, when it was agreed not to proceed further with the removal of the new growth because of the following reasons: The walls of the tumor were bounded posteriorly by the intestines, which were matted together; by the abdominal parietes in front, and by the internal genitals below. The lining membrane of the cavity of the tumor and the surface of the bowels were studded with caseated nodules. The right ovary was deeply imbedded in adhesions which were fully separated and the organ released; it presented a bulging sac filled with cheesy masses. The wall of the uterus likewise contained these caseous bodies. Both tubes were distorted by rigid, many-angled enlargements containing caseous granulations, and the walls showed tubercular degeneration.

A similarly interesting case was published by Gehle from Czerny's Clinic in Heidelberg.

Tuberculosis of the tube, as of other organs, may be acute or chronic. Two cases of the acute variety (which is rarely met with in practice) have been reported by Rokitansky and Wernich. In both patients the disease was bilateral, and in the one of the former the uterus was similarly affected. Wernich's case was an interesting one, because the patient, aged 41 years, though having amenorrhoea for two years had conceived and aborted; the tubes were primarily affected and the lungs secondarily.

Chronic tuberculosis of the genital tract is much more common. Hennig found it, in the ovaries, 6 times; right tube, 15; left tube, 12; uterus, 12; vagina, twice. Geil found it, in the ovaries, 0 times; right tube, 44; left tube, 42; uterus, 35; vagina, once. Secondarily, tubal tuberculosis follows uterine and urinary tuberculosis.

Diagnosis.-Chiari and Veit were able to palpate the dilated tubes through the vagina and the abdominal walls; Courty, likewise, diagnosticated this condition by bimanual examination. Hegar made the diagnosis in four cases; the tubes were abnormally fixed, adherent to the pelvic wall, uterus and broad ligament, and were beset with a wreath-like mass of firm nodules.

The uterine secretion should be examined for tubercle bacilli, and hereditary predisposition receive due attention.

Treatment.-Tubercular amenorrhoea and dysmenorrhoea do not require any treatment. Salpingotomy will not often be indicated, even in isolated primary tubal tuberculosis, since it is almost impossible to exclude constitutional involvement. Hegar has published the results of four such operations, but, as three of them were performed in 1885, it cannot be proved that the patients were benefited thereby; and in the patient operated upon in 1883, the apex of the left lung was affected one and a half years later. Moreover, the tube is liable to be lacerated in the operation; the vessels must be secured in the lowest portions of the abdominal cavity, and it is very difficult to remove all affected parts. I do not, therefore, believe that salpingotomy for tubal tuberculosis has a very promising future.

SECTION V.

ANOMALIES AND DISEASES OF THE OVARIES.

CHAPTER I.

THE ovaries may (1) be entirely absent; (2) be rudimentary; (3) be deformed by constrictions, and (4) be supernumerary.

a. Absence of One or Both Ovaries.

Absence of one ovary occurs in conjunction with uterus unicornis; absence of both, with total absence of the uterus.* When one side seems to terminate too abruptly, either in the normal or malformed uterus, tube and ovary, the ovary which was originally present may have been destroyed by torsion, constriction, and subsequent atrophy. The ovaries may also be found abnormally high in the abdominal cavity, being nourished by adhesions with other organs, and may, indeed, show cystic degeneration, according to Klob. Traces of foetal constriction will be recognized in the form of pseudo-membranes, usually most numerous at the end of the tube belonging to the ovary. The two most interesting cases of this class are those of Rokitansky and Heschl, which have been reported in full by Klob. Both were examples of foetal constriction.

A case of ovarian displacement due to omental adhesions will be referred to in the following chapter, in which the constriction of the ovary might have occurred in adult life, from the firm fixation of the organ, and the elongation of its pedicle and the corresponding tube.

Morgagui and Cripps have observed absence of the ovaries in connection with a foetal uterus. Figure 85 is an illustration of unilateral absence of the ovary in primary atrophy of the uterus,

* Vide section iii., chap. i., figs. 14 and 15.
† L. c., pp. 328-329.

a condition which has been fully described upon page 220. A thin adhesion of connective tissue (b) extending to the rectum

Primary Atrophy of the Uterus (Uterus Membranaceus). Absence of the right (b) and atrophy of the left (a) ovary. d, fundus; e, external os; f, bladder; c, rectum, transversely divided.

represents the absent right ovary. The preparation was from a girl, aged fifteen years, who died from phthisis and extensive glandular suppuration.

b. Rudimentary Development of the Ovary.

This may consist in complete absence of the Graafian follicles, the ovarian stroma being present; or, in the disappearance, either partial or complete, of the follicles after having once been developed. If the former, we find the rudimentary ovary flattened, and composed solely of connective tissue with traces of muscular fibres and vessels, as in fig. 85, a. It may be associated with ab