in general the same change takes place in the acute exanthetnata, as shown by Lebedinsky's examinations after scarlet fever. Lebcdinsky found that at first the microscopical appearance of the ovaries was not clumged, the microscope alone showing parenchymatous inflammation of the follicles in all stages. The following is the final result: Destruction of a larger or smaller number of the follicles with the formation of cica trices, with consequent destruction of the ovarian function to a greater or less extent, so that even the reproductive power of the subjects in ques tion may sometimes be doubtful. It is not necessary to dwell particularly upon the question of how far these conditions are to be classed with those before-mentioned. Myschkin pointed out that the same changes iu the parenchyma of the ovary as were found in infectious diseases were pro• duced by phosphorus and arsenic, while Ilinsburg showed that mercury had a similar influence. Puech attributes an exquisite example of pre mature atrophy of the ovaries to alcohol, " which, as well as opium, must cause amenorrhcea and disappearance of the ovaries."' 3. We turn now to diseases of the genital organs. Some reference has already been made to parenchymatous ofiphoritis. To what hs.s already been said, we must here refer again, inasmuch as the majority of the etiological factors that produce this form of inflammation were de scribed, and the influence of this affection upon the sexual life of the patients has already been noted. According to Slavjansky's work, wo must add to the parenchymatous otiphoritis caused by acute infectious disease and toxic influences a similar form due to local troubles. Thus Slavjansky observed in general and localized peritonitis (which I consider extremely important in its bearing upon the study of the sudden establish ment of the menopause) a parenchymatous inflammation, which is only to be distinguished from the before-mentioned variety by the fact that, advancing from the periphery to the centre of the ovary, it attacks the follicles without reference to their maturity, nor the youngest first and the riper ones subsequently. The final effects upon the function of the organ, which are of interest to us, are. if the inflammation is equally intense, confounded with those of the other form.
In the puerperal state the interstitial form of oophoritis is most com mon, and puerperal affections are generally the principal cause of this variety. The rare cases of diffuse hypertrophy and sclerosis of the stroma or of small purulent foci in the same, in non-puerperal patients, already originate, according to Slavjansky, in a former confinement. Interstitial oophoritis terminates in abscess-formation, especially after previous forma tion of adhesions or hyperplasia and sclerosis of the stroma. The prog nosis with regard to the persistence of isolated healthy follicles is twice as favorable as in parenchymatous otiphoritis. Yet, in these cases too, the loss of function in the ovary can be accounted for, either through severe secondary inflammation of the parenchyma, in which all the follicles are sacrificed, or through the formation of such a thick layer of sclerosed tissue at the periphery, that the follicles can not rupture and thus again they are destroyed. Brierre de Boismont reports a case of complete destruction of the parenchyma of the ovary in consequence of suppura tion; the destruction of the ovary from purulent peritonitis, salpingitis, and oophoritis is demonstrat,ed at autopsies. We recall here some state ments of Olshausen's as comprehensive indications in the examination of the living subject. In abscess of the ovary (an unusual termination of
the inflammation, generally affecting only one ovary) the organ may be enlarged to the size of a man's bead, and the pus frequently is not dis charged, in one or another locality, until after a long interval. In con sequence of hyperplasia of the stroma, the organ may become as large as a hen's egg or the fist, while it preserves its normal shape and feels like a very hard mass, commonly called " hypertrophy of the ovary." Finally, aft,er interstitial inflammation the connective tissue may undergo a process of cicatricial contraction (so-called granular atrophy, or cirrhosis of the ovaries), " which, in consequence of contraction of the external surface at several points, leads also to destruction of the follicles, and thus produces a sort of premature involution of the ovaries. The ovaries may conse quently become unusually small, about the size of a hazel-nut." As regards inflammatory conditions of the uterus, IIegar thinks that the presence of old firm hypertrophied connective tissue, is a condition of frequent occurrence in amenorrhcea, but that it is " partly or entirely dependent on ovulation" has hitherto not been sufficiently made out. Moreover, in a recently-reported case of Durand's, in which suppression of the lochia occurred on the fourth day after delivery, and subsequent persistent antemia (although the molimen persisted for years), the uterus was found to be enlarged.
Of equally doubtful value as regards our subject, is atrophy of the uterus as observed under different conditions. We only consider here in a preliminary way that form of atrophy which follows puerperal metritis. The amenorthcea that attends this condition can only be explained by a simultaneous affection of the ovaries. How far this accords with the condition in the above-mentioned forms of atrophy of the uterus, we shall see below. In general the inflammatory conditions of the uterus (at least up to this time) furnish scarcely any explanatory hint concerning the abnormal appearance of the menopause, which we are now studying.
As regards the inflammatory processes in the vicinity of the internal sexual organs, the case is different. That which concerns us most is the inflammation of the periphery of the ovary, so-called peri-oophoritis. According to Slavjansky, this occurs in parenchymatous oophoritis, usually only as a localized, circumscribed process; certain spots on the external surface (corresponding to the more deeply situated diseased follicles), become the seat of fibrous, papillary bodies, consisting of con nective tissue, which is sometimes newly-formed and rich in cells, some times composed of coarse fibres. Again, when the inflammation at the periphery is intense, pseudo-membranes develop, which lead to adhesions; however, between their points of attachment there still remains a con siderable portion of the surface of the ovary which is unaltered. More often peri-oophoritis accompanies interstitial inflammation of the ovaries, and then usually extends over the entire periphery of the organ. Pseudo membrane may form and enclose the ovary like a capsule, and in conse quence, " even in very slight forms of interstitial oophoritis, in which the newly-formed stromal tissue is not so extensively altered," the follicles may be destroyed, since this capsule, just like the above-mentioned sclerotic layer of connective tissue in simple interstitial oliphoritis, pre vents them from rupturing.