594 HEEBEET M. EVANS 



necrosis and bleeding. Hence some menorrhagias may be referred to this 

 cause, though it is commonly believed that in such conditions increased 

 contractile power of the myometrium would prevent excessive bleeding. 

 There are known to us two conditions which are apparently associated with 

 ovarian hyperf unction. In neither case (on account of our ignorance of 

 the interrelationships of the endocrin glands) do we know whether the 

 ovarian function is primary or induced. I refer to osteomalacia, where 

 Eontgen or surgical sterilization has a clearly curative effect, and to the 

 idiopathic condition known as true pubertas prsecox. 



1. Disturbances Producing Amenorrhea. Ovarian hypofunction usu- 

 ally expresses itself by scanty menstruation (oligomenorrhea), too fre- 

 quent menstruation (polymenorrhea) and by a final cessation of the men- 

 strual function (amenorrhea). It is true that while true amenorrhea is 

 always associated with lack of function of the ovaries, the ovarian disorder 

 can be either primary or secondary. In the latter case it may be invoked 

 by many other conditions so that we are not at liberty to at once draw the 

 inference of gonadal deficiency and institute a therapy directed toward that 

 end. But the new viewpoint of the primacy of the gonads does not permit 

 us in either case to interpret menstrual cessation as uterine trouble. It 

 makes much of the lore concerning amenorrhea treatment and especially 

 the use of "emmenagogues" now appears to us as useless. Just as the 

 etiology of amenorrhea is to be found in ovarian dysfunction, either pri- 

 mary or secondary, so is the cure of it to be sought in a restoration of the 

 gonads either by direct or by indirect procedures and not by attention to 

 the uterus. 



A. Primary Ovarian Involvement. When amenorrhea is due to pri- 

 mary ovarian involvement 24 we are usually able to discover : 



1. Congenital hypoplasia of the reproductive system ; 



2. The cessation of ovarian function is due to a peculiar degenera- 

 tion of its follicular apparatus the so-called small cystic degeneration of 

 the ovary. Based on its etiology it is difficult to give this ovarian disorder 

 its proper place. The secondary nature of this disease may be demon- 

 strated by its occurrence in various other affections which in turn have 

 injured the ovary, but there are other instances in which it appears 

 to exist as a condition sui generis. Frankel has given an excellent descrip- 

 tion of such cases. It is perhaps only fair to say that we are entirely 

 in the dark as to the cause of this aberrant behavior of the follicles, which 

 some view as having been stimulated to begin ovulation in great numbers 

 but to have been overtaken by a cystic transformation before they can 



24 It would hardly seem necessary here to comment upon the physiological cases 

 of amenorrhea or lack of menses. This, of course, occurs in the prepubertal time 

 but also during the period of sexual life in pregnancy and through at least the early 

 part of lactation. In both of the latter instances ovarian activity is manifested through 

 long continued function of the corpus luteum which always depresses follicular growth 

 and the recurrence of new cycles. 



