According to Olshausen, an affection much more important than this secondary peri-oOphoritis, which accompanies pueiperal interstitial oiiphoritis (and is also, as a rule, associated with general peritonitis), is primary peri-oophoritis, the most frequent cause of which is the ext,en sion of inflammation from one of the tubes, gonorrliceal infection, acute catarrhal inflammation, or sometimes acute inflammation, suppression of the menses. These inflammations which extend from the tubes need not be exactly acute in character; there are often repe,ated attacks, which lead to the formation of exudations that surround the ovaries. The latter are often found, under these exudations, unusually small, hard, and generally with a smooth exterior. According to the author just mentioned, this is " a condition of quite simple atrophy of the glands as a result of pressure and obstruction of the blood-supply." The symptoms of this inflamma• tory process are naturally so blended with those of other forms of circum scribed peritonitis, that Olshausen could properly remark that what he called peri-oophoritis, could in the majority of cases be described equally well as peritonitis. In like manlier, as far as our observations go, all the similar inflammatory processes in the vicinity of the pelvic °Tans possess the same significance as the process in question, provided only that the ovaries share in the trouble to a corresponding extent.
Finally, passing mention should be made of parametritis chronica atrophicans (Freund), since premature menostasis is described as one of its results. Schultze thinks that this affection is a later stage (perhaps also a more intense form) of the chronic and sub-acute parametritis which he had observed. Bandl seems inclined to lay to this affection all the profound disturbances of nutrition and of the nervous system, which he has frequently seen to persist for a long time after the parametritis has apparently run an entirely favorable conrse. The entire process, of course, requires further proof and more careful study. However, if we connect the partial amenorrlicea described by Schultze, and the " quite frequent" enlargement and sensitiveness of the ovaries in simple para metritis posterior, with the premature menostasis which we have attri buted to a supposed more intense process, then it occurs to us involun tarily that possibly the latter should be explained as having an im portant bearing upon our subject. We might mention atrophy of the uterus after difficult labors, as a not uncommon cause of the premature establishment of the menopause. Some other forms of atrophy of the uterus belong under the same head.
Severe puerperal lesions cause this condition by producing more or less extensive inflammatory processes, leading to atrophy. Among these are included puerperal inetritis (to which reference has already been made), para. and perimetritis, etc. Another form is simply so-called " puerperal super-involution " of the uterus, in the production of winch previous inflammation is supposed to take no part. Hegar mentions a case of Courty's, in which after a normal labor, the periods returned only once in a year, while the uterus became so much atrophied as to resemble the senile organ, even the cervical canal being obliterated. How far also obscure inflammatory processes may share in causing simple puerperal super-involution is obviously uncertain. Cases of marked atrophy of the uterus from other causes belong here, such as Louis Mayer's case of cessation of tile menses in consequence of a violent fright, and subsequent demonstrated degeneration of the uterus, in a woman of thirty-four. Atrophy of the uterus from pressure by adjacent or super-incumbent tumors (such as sub-peritoneal fibroids, solid ovarian tumors, or large immovable exudations) possesses less interest for us, and we shall, more over, consider these conditions elsewhere from a different standpoint.
Filially, there is another interesting form of atrophy which is mentioned in the works of Scanzoni and Mayrhofer, on the authority of Slob. This is due to defective innervation of the pelvic organs, such as occurs in dif ferent forms of paralysis. Young women, who were previously quite healthy, and bad menstruated regularly, who are subsequently affected with paralysis of the lower half of the body, suffered from this time for wards with amenorrluea, while their uteri were extremely small, a condi tion " which could sometimes be demonstrated on autopsy to be due to true atrophy of the organ." When we consider these different forms of atrophy of the uterus in their relation to the accompanying amenorrhcea, we cannot avoid the conclusion as regards them in general, that the real primary trouble here is dependent on a change in the ovaries, and that the atrophy of the uterus, as well as the amenorrhcea itself, belongs only to the series of secondary changes. I hold, at least (being supported in my opinion, partly by a review of the cases themselves, partly by their analogy to similar and well-authenticated cases) that it is not illogical to assume in every case Irom the outset a distribution of the ovarian function, even when the grounds for this belief are quite small, or even entirely absent. The atrophy of the uterus, however, should then be simply regarded again as the retrograde metamorphosis of the excretory duct of a gland that has become functionally useless, entirely analogous to the comparison of Ilegar's already mentioned at the beginning. This view is partly sup ported by the words of the author just quoted, if I interpret these rightly. In contrast to the above-mentioned " puerperal " forms of atrophy with amenorrhwa, he alone observes that, although unfortunately sufficiently numerous and exact anatomical investigations are wanting, yet doubtless, " through inflammatory processes in the vicinity of the ovaries these organs are compressed and diminished in size, or suffer in some other way changes of structure, whereby the follicles may be completely de stroyed." This exclusive reference to the condition of the ovaries seems to me to show that Hegar in the question at issue also, thinks that the ultimate cause of the trouble is in these organs. As regards, further more, atrophy of the uterus after suppression of the menses, we have already referred to the opinion defended by Olshausen, that primary oophoritis is produced by extension of an acute inflammation through the tubes. The theory of " ovarian causes" was thus supported, in at least the majority of those cases in which the outbreak of such an acute in flammation corresponded to the original injury. Finally, amenorrhces in the last-mentioned variety of atrophy of the uterus, is also produced by defective innervation of the pelvic organs in consequence of different paralytic conditions, which are regarded by the authors just cited as de pendent less upon an abnormality of the uterus " than upon the atrophied condition of the ovaries, which is almost never absent in these cases.'' The propriety of attempting to establish a relation between early development of the menopause and well-marked atrophy of the uterus, seems to me to be, so far at least, doubtful. We are able to erase the latter from the list of causal factors, and to include it among the above mentioned sequelie, just like senile atrophy after the normally-occurring climacteric.