DISEASES OF THE OVARIES (Continued).
HERNIA OF THE OVARY.
Hernia of the ovary may take place through the inguinal ring.
Congenital hernia of the ovary is extremely rare. Bland Sutton says
that there is no properly authenticated case. Notwithstanding the
frequency of congenital hernia in infants, the ovary has not been found
in the hernial sac at birth.
In cases that have been reported as congenital hernia of the ovaries
the structures have, on microscopical examination, been found to be
testicles, the individual being hermaphroditic.
Acquired hernia of the ovary is of not infrequent occurrence. The ovary
may occupy the hernial sac alone or along with other structures.
Ovulation may occur normally, and conception may take place. A true
corpus luteum has been found in an ovary contained in a hernial sac.
The ovary may remain in the inguinal ring or may pass into the labium
majus. In some cases no trouble whatever arises from this displacement.
Hernia of the ovary has been found accidentally at autopsy, having been
entirely overlooked during life. In other cases swelling and severe
pain may be experienced at the menstrual periods.
The ovary is exposed to the dangers of congestion and inflammation.
Adhesions may result, and suppuration has occurred. In such cases the
symptoms of ovaritis are present.
The =diagnosis= of hernia of the ovary is made from palpation of
the gland; from the determination, by bimanual examination, of its
connection with the uterus; from the characteristic sickening pain
experienced upon pressure; and from the swelling and increased pain at
the menstrual period.
The =treatment= is the same as that applied to hernia of any other
structure. The hernia should be reduced if possible, and retained by a
truss; or the ring may be closed by radical operation for hernia. If
the ovary is adherent, operation is necessary before reduction can be
accomplished. If the ovary is itself grossly diseased, its removal may
be necessary.
PROLAPSE OF THE OVARY.
Prolapse of the ovary is a downward displacement of this organ behind
the uterus. Various degrees of prolapse occur, from a slight descent to
complete prolapse in the bottom of Douglas’s pouch.
There are two general kinds of ovarian prolapse. In one the uterus is
primarily the displaced organ, and when prolapsed, retroverted, or
retroflexed, it drags the ovaries out of place with it. Such cases have
been referred to in discussing uterine displacement. If the ovaries
are not adherent, they usually return to the normal position when the
uterus is replaced. Similar to this kind of displacement of the ovary
is that which occurs in disease of the Fallopian tubes, which, when
enlarged, descend and drag the ovaries with them. In the other variety
the displacement is primary in the ovary, and occurs independently
of any displacement of the uterus or other structure to which it is
attached. It is such prolapse that will be considered here.
There are various =causes= of ovarian prolapse. In some cases it is
probable that the position of the ovaries in the bottom of Douglas’s
pouch is congenital.
A sudden strain or effort is said to have produced acute prolapse of
the ovary.
Anything that increases the weight of the ovary may cause its descent.
Prolonged congestion, inflammation, or small ovarian tumors may result
in ovarian prolapse.
Subinvolution is the most frequent cause of ovarian prolapse. In
pregnancy the ovaries become very much enlarged, especially the left
one. The ovarian ligament and the infundibulo-pelvic ligament become
much increased in length. If, after labor, involution is arrested or is
incomplete for any reason, the conditions favorable for prolapse of the
ovary will be present--increased weight of the ovary and relaxation and
lengthening of its attachments. Sometimes the cause of the prolapse is
in the ligaments alone. The ovary may have returned to its normal size,
while the ligaments may have remained subinvoluted, permitting undue
freedom of movement.
The left ovary is more frequently prolapsed than the right. There are
two reasons for this difference. As has just been said, the left ovary
becomes more enlarged during pregnancy, and therefore suffers more from
subinvolution, and the arrangement of the veins on the left side is
such that venous congestion is very liable to occur.
When prolapse has existed for a long time, secondary changes take place
in the ovary as the result of hyperemia, and the condition becomes
further aggravated.
=Symptoms.=--Slight descent of the ovary very often causes no suffering
whatever. When, however, the ovary is completely prolapsed, lying in
the bottom of Douglas’s pouch, between the posterior wall of the vagina
and the rectum, well-marked symptoms usually arise.
The woman suffers pain whenever she is in the erect position. The
pain is increased by walking, probably because the ovary is squeezed
between the cervix and the sacrum. Coitus sometimes causes intense
pain. Defecation causes pain. The pain begins with the movements of
the bowels, and often lasts for one or two hours afterward. It is dull
and aching in character, and is situated in the normal position of the
ovary, radiating thence throughout the pelvis and extending down the
thighs. It frequently produces faintness and nausea.
The ovarian pain is markedly increased at the menstrual periods.
The general and reflex disturbances produced by prolapse of the
ovary are often very pronounced. There may be headache, indigestion,
hysteria, and great mental depression. A reflex pain is often felt in
the breast on the same side with the affected ovary.
Bimanual examination usually reveals the condition. The prolapsed ovary
may readily be felt by the vaginal finger. If the finger is introduced
high up behind the cervix, and is then turned with the palmar surface
backward, the ovary may be caught between the finger and the sacrum.
The irregular surface of the ovary, due to the prominent vesicles
and the old scars, may often be felt. When the ovary is pressed upon
there is a characteristic sickening feeling experienced by the woman.
Sometimes she cries out with intense pain even upon the gentlest
pressure on the ovary. After witnessing such pain the physician
realizes the extent of the suffering experienced in walking, at coitus,
and at defecation. If the ovary is not adherent, it may slip from the
examining finger, and perhaps may not be felt again until a subsequent
examination, after it has returned to its prolapsed position.
A large prolapsed ovary has often been mistaken for the fundus uteri,
and has caused the diagnosis of retroflexion to be made. This mistake
will not occur if the examiner determines the real position of the
uterus by palpation or by the sound. The uterus may usually be moved
independently of the prolapsed ovary.
=Treatment.=--The treatment of ovarian prolapse depends upon the cause
of the condition. Prolapse of the ovary caused by uterine displacement
is usually cured by the treatment that restores the uterus to its
normal position.
Prolapse of the ovary accompanying tubal disease and prolapse caused
by small ovarian tumors demand operation and removal of the tube and
ovary.
When the ovary is not adherent, it may sometimes be restored to its
normal position, or at least be considerably elevated, so that the
suffering is much relieved, by placing the woman in the knee-chest
position and opening the vagina. In this position all the pelvic
structures are carried upward.
A pledget of cotton or wool placed back of the cervix, in the posterior
vaginal fornix, will often give great temporary relief. The cotton may
stay in the vagina for twenty-four to forty-eight hours.
The woman should be advised to assume the knee-chest position, allowing
air to enter the vagina by introducing the nozzle-piece of the vaginal
syringe, once or twice daily. The best time is immediately before
retiring at night, and she should afterwards sleep as much as possible
on the side, in the Sims position. She should remain in the knee-chest
position for several minutes--until tired.
In addition to this treatment, the pelvic congestion should be relieved
by continuous use of saline laxatives, by hot-water vaginal douches,
and by occasional applications of Churchill’s tincture of iodine to the
vaginal vault, and the use of the glycerine tampon. If the prolapse has
been caused by subinvolution of the ovary and its attachments, such
treatment may ultimately result in cure. The enlarged ovary diminishes
in size and weight, and its ligaments contract and regain tonicity.
Subinvolution of the uterus is often also present. This condition
should be treated as has already been advised.
In many cases of ovarian prolapse there have taken place in the
ovary secondary changes that resist such treatment even when most
conscientiously applied. The physician is then driven to the operation
of oöphorectomy as the only method of relieving the intolerable
suffering. This operation should never be performed, however, until
other milder treatment has been carefully tried, and unless the
suffering of the woman incapacitates her for the duties of life.
In some cases in which the ovary is not itself grossly diseased it may
be possible to avoid oöphorectomy, and to correct the displacement
by attaching the ovary by suture to the upper margin of the broad
ligament, or by shortening the infundibulo-pelvic ligament by suture.
If the ovary has become adherent in Douglas’s pouch, the condition can
be relieved only by operation--celiotomy, and usually oöphorectomy.
A variety of pessaries have been invented for the relief of ovarian
prolapse. They are of but little, if any, use. In many cases the
pressure of the pessary upon the ovary renders its employment
impossible. No pessary will cure a simple prolapse of the ovary. The
cases in which the pessary does good are those in which there is a
primary uterine displacement.
INFLAMMATION OF THE OVARY; OÖPHORITIS OR OVARITIS.
=Acute Oöphoritis.=--In acute oöphoritis the inflammation may begin
on the surface of the ovary (_perioöphoritis_) and extend inward,
or it may begin in the ovary itself. When the disease is caused by
extension of the inflammation from the tubes, it usually begins as a
perioöphoritis. Both the follicular and interstitial portions of the
ovary may be affected. When the inflammation is confined chiefly to
the ovarian follicles, it is said to be _parenchymatous_; when the
connective tissue is chiefly affected, it is called _interstitial
oöphoritis_. In acute inflammations all portions of the ovary are
usually involved at one time.
The changes are those that characterize inflammation of other glandular
structures. The whole organ becomes swollen, hyperemic, and edematous.
The liquor folliculi becomes turbid; the membrana granulosa becomes
softened and disintegrated. The surface of the ovary may be covered
with an inflammatory exudate. In severe septic cases the whole ovary
may become destroyed, or one or more ovarian abscesses may be formed.
In less severe cases the inflammation subsides before suppuration takes
place, or goes on to chronic oöphoritis.
The usual _cause_ of acute oöphoritis is extension of inflammation from
the Fallopian tube.
Acute oöphoritis may also occur as the result of septic infection
carried by the lymphatics of the uterus. The disease is not uncommon
in puerperal sepsis. Here it often forms but a minor part of a general
fatal infection.
Gonorrhea may cause oöphoritis in a similar way.
Acute suppression of menstruation is said to result in inflammation of
the ovaries.
Acute rheumatism and the eruptive fevers may produce oöphoritis. The
disease of the ovaries is often overlooked during the acute attack,
while the attention of the physician is engaged by the general
affection. These diseases, occurring in childhood, are the probable
causes of some of the damaged and chronically inflamed ovaries with
which women suffer in later life. To these diseases also are to be
attributed many cases of arrested development of the sexual apparatus,
the phenomena of which appear only after menstruation has begun.
The ovarian disease in these cases may be very insidious. Decided
microscopic changes have been found in the ovarian follicles in scarlet
fever, though to the naked eye the gland was unchanged.
The _symptoms_ of acute oöphoritis are very often masked by those of
accompanying affections, such as salpingitis and puerperal sepsis.
There may be a chill, followed by fever, nausea, and vomiting.
The pain is that which characterizes any local pelvic inflammation. It
is most intense in the ovarian regions.
Bimanual examination may reveal the enlarged, tender ovaries, which are
very often prolapsed behind the uterus.
The greatest gentleness should always be observed in making a vaginal
examination in any case of inflammation of the pelvic structures, not
only to avoid inflicting unnecessary pain, but because a much more
satisfactory examination can be made if the woman does not fear and
resist the examiner.
_Treatment._--The treatment of acute oöphoritis is expectant. It is
similar to that already advised for acute salpingitis. The physician
should prescribe absolute rest in bed; hot fomentations over the
abdomen; saline laxatives; and warm vaginal douches of sterile water if
the pain is not increased by them.
[Illustration: FIG. 161.--Cystic ovary.]
If suppuration occurs, immediate laparotomy with removal of the
diseased structures should be practised. If the acute inflammation
subside, subsequent operation may be necessary for the chronic
inflammation.
=Chronic Oöphoritis.=--Chronic oöphoritis, like the acute form, may
be either parenchymatous or interstitial. Usually both the connective
tissue and the ovarian follicles are involved. The disease is usually
bilateral. The tunica albuginea may become much thickened, and
adhesions may form between the ovary and the adjacent structures.
In practice we find chronic oöphoritis in two forms: The ovary may be
cystic, filled with a number of cysts of varying size up to that of
a marble (Fig. 161). These cysts are transformed ovarian follicles.
The walls are thickened, and the ova and the membrana granulosa have
undergone fatty degeneration and absorption. The fluid in the cysts
may be clear, cloudy, bloody, or gelatinous. Sometimes the septa are
absorbed, and several cysts are thrown into one cavity. The connective
tissue of the ovary is increased in amount.
The ovary becomes enlarged, though it rarely exceeds the size of a
hen’s egg.
[Illustration: FIG. 162.--Cirrhotic ovary from an old maid forty years
of age.]
It is probable that this form of inflammatory change is the origin of
some kinds of small ovarian cystic tumors.
In the other form of chronic oöphoritis the interstitial changes are
most marked. There is a decided increase of the connective tissue,
and a diminution of the parenchymatous or follicular structures.
The ovary is hard and cirrhotic, and is of a lighter or paler color
than normal; the visible ovarian follicles are few; the greater part
of the ovary appears to be a mass of wrinkled connective tissue; in
some cases the follicular structure is confined to but one-quarter of
the ovary. The changes resemble and are similar to those that take
place physiologically in the ovaries of old women (see Fig. 162).
Between these two types of cystic and cirrhotic ovaries various forms,
combinations of the two, may occur. The ovary upon one side may be
cystic, upon the other cirrhotic.
The _causes_ of chronic oöphoritis are various. The condition may
persist after the subsidence of acute oöphoritis. It is usually
secondary to salpingitis. There are very few cases of chronic
salpingitis that are not accompanied by some form of oöphoritis. The
disease may be chronic from the beginning. It may develop slowly from
septic or gonorrheal infection from the uterus. It may result from
subinvolution or prolapse of the ovary.
It may result from immoderate sexual irritation, and from unnatural
gratification of the sexual impulse.
It seems probable also that chronic ovaritis may occur as the result
of celibacy or sterility. The unceasing menstrual congestions of the
virgin or the sterile woman, which, as has already been pointed out,
seem to predispose the woman to fibroid changes in the uterus, seem
likewise to develop the growth of connective tissue in the ovary.
Virgins between the ages of thirty and forty often present hard
cirrhotic ovaries with decided diminution of the follicular elements.
The condition is often associated with a fibroid state of the uterus,
this organ being indurated from interstitial fibroid deposit, or
presenting one or more subperitoneal nodules.
_Symptoms._--The most prominent symptom of chronic oöphoritis is pain.
The disease is usually bilateral, and the pain affects both ovarian
regions; it is, however, usually more marked upon the left side. The
pain is increased by the erect position and by exercise, defecation,
and coitus. Pain at defecation and coitus is most marked when ovarian
prolapse accompanies the inflammation.
The pain is increased at the menstrual period. It is most intense
immediately before and at the beginning of the flow. If the bleeding is
profuse, the pain is often relieved.
Menorrhagia often accompanies chronic oöphoritis, and seems to occur
chiefly with the cystic variety of the disease. As most cases of
oöphoritis are accompanied by endometritis and salpingitis, it is
difficult to determine how important a part in the production of the
menorrhagia is played by the ovarian disease. Reflex pain in the region
of one or both breasts, usually the left, is often complained of.
The reflex disturbances caused by chronic oöphoritis form a very
important part of the woman’s suffering. Loss of appetite, digestive
disturbances, nausea, and vomiting occur. Hysteria, profound mental
depression, and various cerebral derangements take place. Sterility
may be caused by chronic oöphoritis if the ovarian capsule becomes so
thickened that rupture of ovarian follicles cannot take place.
Bimanual examination should be performed with great gentleness. The
condition of the ovary may be most satisfactorily determined in those
cases in which the ovarian lesion is the chief trouble and in which the
tubes and other pelvic structures are not coincidently inflamed. If the
ovary is felt, it is found to be very tender and usually enlarged. In
cases of long-standing interstitial inflammation the ovary may be below
the usual size. Palpation is very easy if the ovary is prolapsed in
Douglas’s pouch.
Chronic oöphoritis rarely recovers spontaneously. The woman may
have periods of relief, but the symptoms may all recur after some
indiscretion or unusual exercise. Suffering usually diminishes, and
may in time cease, after the menopause, when atrophy takes place and
menstrual congestions have stopped.
_Treatment._--Chronic oöphoritis usually requires operative treatment
(salpingo-oöphorectomy), because it is associated with disease of
the tubes. In other cases a great deal may be accomplished without
operation, and the woman may be tided over the period of menstrual life
until permanent relief is secured at the menopause.
This palliative treatment is usually applicable, however, only to those
women who are not dependent for a living upon their own labor. It is
best to begin the treatment by putting the woman to bed for one or two
months; to administer daily massage; to maintain mild purgation with
saline purgatives; to make, once a week, applications of Churchill’s
tincture of iodine to the vaginal vault, followed by the glycerin
tampon; and to give hot-water vaginal injections twice a day.
If there is any disease of the uterus, such as laceration of the cervix
or endometritis, this should be treated first.
After the woman leaves her bed the douches, saline laxatives, and
vaginal applications should be continued. Absolute rest in the
recumbent posture should be prescribed at the menstrual periods, and
at other times if the ovarian pain becomes severe. Coitus should be
forbidden during the treatment. If the woman is unable to begin the
treatment by prolonged rest, the subsequent part of the treatment
advised here may be followed.
This treatment always does good for a time. Unfortunately, its results
are not often permanent. The old pain and suffering return as soon as
the woman ceases to be under medical care. If the inflammatory changes
have become well established, no permanent good results from any
medical treatment. This is especially true in those cases in which the
original causative state of things continues after treatment is given
up. If the cirrhotic ovaries are the result of celibacy, medicine can
be but palliative.
Working-women are unable to obtain the proper medical treatment,
especially when the prospect of cure is doubtful, and therefore, if
their suffering incapacitates them, must be subjected to the operation
of oöphorectomy.
In any case oöphorectomy should be advised if the suffering persists
after carefully tried medical treatment.
APOPLEXY OF THE OVARY.
Hemorrhage may take place either into an ovarian follicle, in which
case it is called follicular hemorrhage; or it may take place into the
ovarian stroma; to this condition the term ovarian apoplexy is applied.
Hemorrhage into the follicles is usually small in amount, the distended
follicle rarely exceeding the size of a hickory-nut. In case of cystic
degeneration of the ovary small blood-filled cysts may be present,
formed by the fusion of several follicular cysts. Occasionally the
amount of blood in the follicle is enough to cause its rupture. If the
follicle should rupture into the peritoneum, a small hematocele would
result. If the follicle ruptures into the ovarian stroma, ovarian
apoplexy occurs.
Follicular hemorrhage and ovarian apoplexy are most liable to occur
during the congestion of a menstrual period.
Such hemorrhages are not infrequent in the acute fevers and in
scurvy. The symptoms of the condition are in no way characteristic.
If the exact state of the ovary were known from previous examination,
follicular hemorrhage or apoplexy might be suspected from the detection
of a sudden ovarian enlargement and pain unaccompanied by symptoms of
inflammation.
The blood is usually absorbed, and unless some accompanying disease of
the ovary is present, spontaneous recovery will result.
OVARIAN HYDROCELE.
Ovarian hydrocele is a rare disease, the true nature of which has been
explained by Bland Sutton. Most of the cases that have been reported
have been mistaken for tubo-ovarian cysts. The tubo-ovarian cyst has
already been described. It is a cyst that results from inflammatory
disease of the tube, and is formed by the union of the cavities of a
closed Fallopian tube and a follicular cyst in the ovary.
Ovarian hydrocele has a different origin. To understand it a brief
reference to the relation between the ovary and the broad ligament is
necessary. I quote from Bland Sutton: “The ovary projects from, and is
invested by the posterior layer of the broad ligament. When the parts
are examined _in situ_, the ovary will be found to lie in or upon
the edge of a shallow recess in the mesosalpinx. This recess is the
ovarian sac (Fig. 163). It varies in depth; in many it is small and
inconspicuous, whilst in others it is sufficiently deep to accommodate
the entire ovary. In the virgin the ampulla of the tube falls over the
mouth of this recess and conceals the ovary. This relation of parts is
usually disturbed in the first pregnancy.”
[Illustration: FIG. 163.--Left Fallopian tube from an adult (after
Richard).]
Tait[1] says: “In a few exceptions I have seen a crescentic double
fold of the posterior layer of the broad ligament pass down behind
the ovary, covering it like the hood of a ‘Nepenthes’ gland. In all
such cases the women have been sterile, probably because this hood has
prevented the application to the ovary of the opening of the oviduct.
I have seen this arrangement give great trouble in the removal of small
ovaries.” In some animals the ovarian sac is much better developed than
in the human female. In the hyena it forms a complete tunic to the
ovary, the cavity of the sac communicating with the peritoneum by a
small opening. In rats and mice the sac is complete, and the Fallopian
tube communicates with the ovarian sac, but not with the general
peritoneal cavity.
Ovarian hydrocele occurs in women when the abdominal ostium of the
Fallopian tube opens into a well-formed ovarian sac and the common
cavity becomes distended with fluid.
Sutton sums up the peculiarities of ovarian hydrocele as follows:
I. The Fallopian tube opens by its abdominal ostium into a sac on the
posterior aspect of the broad ligament.
II. The tube is elongated, dilated, and tortuous, resembling a retort
with a convoluted delivery tube.
III. As a rule, there is no evidence of inflammation. The cyst may
suppurate should the tube become affected with salpingitis.
IV. In small cysts the ovary will be found projecting on the floor of
the sac. In larger specimens it will be incorporated with the wall of
the sac, and in very large specimens it is unrecognizable.
An ovarian hydrocele may attain considerable size. A case has been
reported in which three pints of straw-colored fluid were found in the
cyst. An ovarian hydrocele is sometimes intermitting, discharging its
contents through the tube into the uterus.
The _symptoms_ of ovarian hydrocele resemble those of a small ovarian
cyst or a tubo-ovarian cyst.
The _treatment_ is celiotomy and removal of the tube and ovary, or,
when practicable, the liberation of the adherent end of the Fallopian
tube.