nervous kinship between the two--so close, indeed, that turgidity in
the one means erectility in the other. Hence it is not always easy to
decide which lesion was primary and which is secondary. When one ovary
is displaced, it is usually the left one, because the left ovary, as
explained under the heading of Ovaritis, is the one more liable to
disease. When both ovaries are displaced, the left one will be the
lower and the more easily reached, because the left round ligament is
the longer and the left side of Douglas's pouch the deeper.
CAUSATION.--Any condition tending to a lasting congestion of the
reproductive apparatus is very likely to lead to a descent of the
ovaries. The causes, therefore, are the same as those of chronic
ovaritis, to which subject the reader is referred.
SYMPTOMS.--First and foremost is pain in locomotion. Since the ovary
now lies between the womb and the sacrum, it is liable at every step to
be pinched between them. This pain is referred to the inguinal and
sacral regions, and is of a sickening and an unnerving character. It
often occurs suddenly, and then runs down the corresponding thigh along
the track of the genito-crural nerve. One of my patients would, while
walking, be unexpectedly seized with such a pain, which would either
momentarily cripple her or else last so long as to compel her to call a
carriage. Her left ovary, until cured by treatment, behaved like a
loose cartilage in the knee-joint, and slipped down so low as to get
pinched.
A second symptom is a throbbing pain while the rectum is loaded, and an
agonizing pain during defecation. This arises from the grating of the
hardened feces over these tender glands. In one of my cases[2] rectal
enemata or the presence of hardened feces kindled up sexual throbs of
the {288} most painful and exhausting character, which thrilled through
the whole body for hours at a time.
[Footnote 2: _Lessons in Gynæcology_, by W. Goodell, M.D., ed. 1880, p.
332.]
A third symptom is painful coition, for the ovaries are now so low down
as to be bruised by the male organ. A fourth is gusts of pain radiating
from either groin. Lastly, there is usually present a morbid state of
the mind, accompanied by low spirits. I have seen suicidal tendencies
evoked by dislocation of the ovaries and relieved by their replacement.
DIAGNOSIS.--A digital examination will discover in Douglas's pouch a
very tender almond-shaped body on one side of the womb. If both ovaries
are dislocated, two such bodies will be found; but the left one, for
reasons previously given, will be lower down and more easily defined.
Pressure upon one of them produces a sickening pain, like that when the
testicle is squeezed. If the pressure be increased, and be so made that
one of these bodies slips abruptly away from under the finger, such a
thrill of indescribable pain darts through the groin and down the side
of the corresponding thigh that the woman screams out and grows pale or
becomes nauseated.
A dislocated ovary is sometimes mistaken for a pedunculated fibroid
tumor of the womb or for the fundus of a retroflexed womb. But the
uterine growth is not sensitive to the touch, and the flexion of the
womb can always be told by the sound.
TREATMENT.--Whenever the dislocated ovaries are congested or they
display signs of chronic inflammation, the same remedies will of course
be useful as those for ovaritis. In addition, pessaries are important
adjuvants, and especially in those cases in which the womb has a
backward displacement. In the simple, uncomplicated cases of ovarian
dislocation, in which the womb is in its proper position, a pessary
often does more harm than good. To be of service it must be long enough
to obliterate Douglas's pouch, and the pressure on the rectum or on the
sacral nerves then becomes unbearable. If, on the other hand, it be too
short, the ovary slips down behind it and gets badly pinched. These
requirements practically exclude the resort to Hodge's pessary or to
any of its modifications, with the exception, perhaps, of Fowler's. In
the long run, a thick elastic and soft ring-pessary will do the most
good, by offering a broad shelf on which the ovaries will sometimes,
but not always, lodge. The air-cushion pessary and Gariel's air-bag
will often answer the purpose better than any other, but, being of soft
rubber, they soon become fetid and soon collapse.
A very excellent way of keeping up the ovaries is the knee-chest
posture devised by H. F. Campbell of Georgia. Two or three times a day,
or more frequently if needful, the woman unbuttons her dress, unhooks
her corset, and loosens her underclothing. She then kneels on her bed
with her body bent forward until her chest is brought down to the
surface of the bed, while her head is turned to one side and the lower
cheek supported in the palm of the corresponding hand. Her knees should
be about ten inches apart and the thighs perpendicular to the bed. The
trunk of the woman's body is now supported, like a tripod, by her two
knees and the upper portion of her thorax. If she now refrains from
straining and breathes naturally, a reversal of gravity will be
established. With the fingers of her free hand she next opens the
vulva. Air will {289} rush in, distending the vagina, and the contents
of the abdomen will at once sink toward the diaphragm. This will, of
course, draw the womb and the displaced ovaries out of the pelvic
basin. As it is rather awkward for a woman while in this posture to
free one hand to reach the vulva, Campbell advises that previously to
taking this attitude she should insert into the vagina a small glass
tube open at each end and long enough to project externally. This will
leave an air-way and dispense with the use of the fingers. After
staying in this posture for a few minutes, the woman removes the tube
and slowly turns over on her side, where she is to lie as long as she
can. Such constant replacements are of great service, for they lessen
the throbbing and they give the limp ligaments a chance of shrinking
and of keeping the truant ovaries at home.
In this intractable disorder an abdominal brace will sometimes do good.
It may not cure, but it often blunts the edge of the aches, and thereby
gives much comfort. By pressing the abdominal wall upward and inward
the brace forms a shelf on which the viscera rest, and thus it takes
off a portion of the load from the womb and from its ovaries. By
virtually narrowing the pelvic inlet it lessens the space into which
the bowels tend to crowd, and to that extent protects the pelvic
organs. By swinging the pelvis backward it makes the axis of the
superior strait lie more obliquely to the axis of the trunk, and the
sum of the visceral pressure now converges, not in the pelvic basin,
but on the portion of the abdominal wall lying between the symphysis
pubis and the umbilicus.
There is yet another treatment which, combined with the knee-chest
posture, I deem the best of all. It is Mitchell's rest-cure, to which I
have before referred. After the patient begins to improve and to
fatten, as she usually does under this treatment, she is taught how to
replace the ovaries by atmospheric pressure, and the result is that in
my experience they finally stay up. The explanation is as follows: By
this treatment the circulation of nerve-fluid and of blood is
equalized, and the ovaries, relieved of their turgescence, grow
lighter. Then the increased deposit of fat in the abdominal walls, in
the omental apron, and around the viscera, to say nothing of the
needful fat-padding in all the pelvic nooks and crannies, increases the
retentive power of the abdomen. Finally, by its gravity the now
fat-laden and overhanging wall of the abdomen tends to draw toward
itself--that is to say, upward--the movable floor of the pelvis. The
behavior is like that of a rubber ball half filled with air, in which
bulging at one pole causes a corresponding cupping at the other. This
explains the ascent of the womb in women who get fat after the
climacteric.
In exceptional cases the hypertrophied glands keep heavy and refuse
either to go up or to stay up under any treatment whatever. The only
known remedy will then be their extirpation--an operation which will be
discussed under its appropriate heading.
Hernia of the Ovary.
This is usually a congenital displacement, and, according to
Englisch,[3] is, when double, almost always so. The ovary is then found
either in {290} the inguinal canal or outside of this canal in the
corresponding labium majus. The oviduct then accompanies it. When the
hernia is acquired, the ovary, with or without the oviduct, makes one
of the contents of the sac of an inguinal, a crural, a ventral, or an
ischiatic hernia. Of these, the inguinal is by far the most common.
Thus, out of 67 cases observed in 9 years by Langlon at the Truss
Society, all were inguinal with 1 doubtful exception. Of these 67, 42
were congenital, 25 acquired.
[Footnote 3: _New Sydenham Soc.'s Biennial Retrospect_, 1871-72, p.
291.]
The character of the lesion is told by the peculiar tenderness and
nausea following pressure, and by the swelling of the tumor just before
the menstrual flux. In one case mentioned by Routh[4] pressure on the
tumor produced distressing sexual excitement; but this is an unusual
symptom, although I have seen it produced by the pressure of hardened
feces.[5] It is not always easy to decide whether the displaced glands
are ovaries or testicles; and repeated mistakes in regard to sex have
thus been made.[6] So difficult, indeed, is it sometimes that the
microscope can alone settle the question.
[Footnote 4: _Trans. Royal Medical and Chir. Soc., Lancet_, Jan. 28,
1882.]
[Footnote 5: Goodell, _Lessons in Gynæcology_, 2d ed., chap. xxvi. p.
332.]
[Footnote 6: Chambers, _Trans. London Obstet. Soc._, 1881.]
TREATMENT.--In a reducible hernia, taxis and an appropriate truss
comprise the treatment. If irreducible, a truss with a concave pad may
be used to protect the ovary from injury. If the ovary be fixed by
adhesions and it give much discomfort, it should be removed by
operation.
Öophorectomy; Battey's Operation.
There are certain forms of diseases of women peculiar to the menstrual
period of life. The attendant lesions are found either in the
reproductive organs themselves or outside of them in remote organs, but
with such monthly exacerbations as show their participation in the
catamenial excitement. They are always very hard to cure, and often
prove to be wholly unmanageable until the climacteric has been
established.
In this category may be classed fibroid tumors of the womb, chronic
pelvic peritonitis and cellulitis, chronic ovaritis and ovaralgia,
ovarian insanity, ovarian epilepsy, and, in short, all those phenomena
or those lesions which are embraced under the term of pernicious
menstruation.
Fibroid tumors of the womb are, fortunately, pretty manageable.
Usually, the womb, like a generous host, hospitably entertains them;
but once in a while an unwelcome one presents itself which arouses all
the resentment of that organ. If, then, it stubbornly resists all
treatment, it slowly but surely destroys life by the pain which it
evokes and by the loss of blood it gives rise to. In such a case the
woman is virtually bed-ridden from her floodings and sufferings, and
she looks forward to the climacteric as her only hope. But the change
of life is then always postponed for several years beyond the natural
term--oftentimes so many years as to be overtaken by the death of the
patient.
Then, again, there are those cases in which, despite all treatment, the
ovaries remain turgid with blood, acutely neuralgic, and to the last
degree sensitive. They become dislocated and lie in Douglas's pouch, or
irremediable tissue-changes take place, attended by follicular or by
{291} interstitial degeneration. A woman with such a lesion is usually
a helpless invalid, racked with atrocious pains, weakened by exhausting
menorrhagia, and wholly unable to fulfil her duties as wife or as
mother. Usually she seeks relief in anodynes and becomes a confirmed
opium-eater.
There are also many distressing cases of salpingitis or of pelvic
peritonitis and pelvic cellulitis which cripple a woman past all hope
by monthly exacerbations. Such cases are by no means rare, and the
woman, reduced to skin and bone, finally dies, because in spite of all
treatment the inflammation is rekindled at every monthly period.
Further, there are cases of epilepsy which seem to come wholly from the
sexual organs--cases with an ovarian aura, so to speak. The fits begin
at puberty, very generally last through life, and end in impairment of
the mind. Often the first convulsion is ushered in by the first
menstruation, and ever after it is around ovulation as a storm-centre
that future eclamptic attacks revolve. Such an epileptic is the terror
of her family and a valueless member of society. Generally she dies
insane or with enfeebled mind, and if she marries she is very likely to
transmit her infirmities to her children, either in the same form as
her own or in kind.
Finally, what insane asylum does not hold incurable women whose mental
infirmities seem to depend wholly upon the act of ovulation? Some there
are who, indeed, never exhibit symptoms of insanity excepting during
the monthly flux.
For these menstrual affections there is a remedy which, while yet in
its infancy, promises much--one first proposed and performed by R.
Battey of Rome, Georgia. This able surgeon reasoned that, since these
disorders are kept up by the monthly afflux of blood to the sexual
apparatus, and therefore incurable during menstrual life, the only
chance of immediate relief lies in the establishment of an artificial
menopause. To bring about this change of life he advocated the
extirpation of both the ovaries, and labeled the operation normal
ovariotomy. With this name fault has been found, because it does not
cover the whole ground, for often the ovaries themselves, together with
the oviducts, are found diseased. Now, since it is important to
distinguish this operation from that of ovariotomy proper, and since
the term spaying, which technically defines the character of the
operation, is obnoxious from its association with the lower animals,
the terms öophorectomy, or Battey's operation, have been adopted.
In well-selected cases this operation has been followed by wonderful
results; but it has been greatly abused. By it I have restored to
perfect health cases of otherwise incurable fibroid tumors of the womb,
cases of dysmenorrhoea and of menorrhagia, and cases of pernicious
menstruation in which the sufferers were reduced to the last degree of
emaciation and feebleness. Out of 5 cases of ovarian insanity I have
also cured 4; the fifth, while not wholly restored, is yet very much
better.
This operation has been performed both by the vaginal and the abdominal
section. For some years I was a warm advocate of the vaginal method,
but I have wholly given it up, because by this method of operation
adherent ovaries cannot be safely dislodged, the ovaries cannot always
be reached, the vaginal wound cannot be dressed antiseptically, {292}
and because the abdominal mode is more simple and less dangerous. Only
when the ovaries are dislocated and low down in Douglas's pouch would I
possibly resort to the vaginal incision.
If the abdominal operation be performed, the incision should be made
between the navel and the pubes in the median line, and not over each
ovary, as advised by some authors. One great caution must, however, be
observed, and that is not to wound the intestines. In ovariotomy the
cyst is in front of the intestines, and there is very little danger of
injuring the latter. But in cases of öophorectomy, no tumor being
present, the bowels lie in contact with the wall of the abdomen, and
are very likely to be wounded by the knife when the peritoneum is
incised. The incision should be long enough to admit two fingers.
These, being passed behind the womb, are conducted to the ovary by
gliding along the oviduct as a guide. Each ovary, together with its
oviduct, is in turn brought up to the opening. It is then seized by a
fenestrated polypus-forceps and its stalk transfixed, tied on either
side with fine silk, cut off, and dropped back into the abdominal
cavity. Should the stalk be so short that ovarian tissue is left behind
in the button of the stump, it should be destroyed by Paquelin's
cautery, for it is astonishing how small an amount of this tissue will
keep up not only menstruation, but even menorrhagia. On the other hand,
it will not answer merely to ligate the pedicles without removing the
ovaries. This has been tried, and not only did menstruation continue,
but in one instance pregnancy took place.[7]
[Footnote 7: Murphy, _British Medical Journal_, April 18, 1885, p.
787.]
The dressing is precisely the same as in ovariotomy, and, like it, the
operation should be performed with every detail of antiseptic surgery.
In the vaginal operation the vagina first should be thoroughly cleansed
with a solution of carbolic acid, and the patient placed on her back
and not on her side. I am convinced from experience that the usual
left-lateral position is a dangerous one, for as soon as the peritoneum
is opened the air rushes out and in during every inspiration and
expiration--an untoward circumstance which cannot happen in the dorsal
position. A duckbill speculum is introduced, and the perineum pulled
downward. The cervix uteri is transfixed by a strong thread, by which
the womb is drawn downward and forward. The post-cervical mucous
membrane is next caught up by a uterine tenaculum and snipped open for
about an inch. The index finger of the left hand is then passed in, and
each ovary brought down to the incision by the finger-tip hooked into
the sling made by the oviduct. The ovary is seized by a fenestrated
forceps and brought into the vagina, where its stalk is transfixed by
passing a needle armed with a double thread between the ovarian
ligament and the oviduct, and each half is securely tied. The ovary and
the fimbriated end of the oviduct are then removed, the ligatures cut
off at the knot, and the stumps returned into the pelvic cavity. To
close the vaginal opening one or two stitches will be needed, and
finally the wound is covered with iodoform and the vagina gently packed
with pads of carbolated or salicylated cotton.
It is a fact worthy of note that during the week following the ablation
of the uterine appendages a sanguineous discharge from the womb usually
takes place. This is in no wise a menstruation, but a metrostaxis {293}
set up by the irritation of the ovarian nerves, caused by the means
adopted to secure the pedicles. Candor, however, compels me to say that
for some inexplicable reason the removal of the uterine
appendages--viz. ovaries and oviducts--does not always bring about the
change of life. These cases are exceptional, and they are supposed to
be due to either the presence of a third ovary or to some small portion
of ovarian stroma left behind.
This operation in no wise unsexes a woman or changes her appearance or
character. It simply brings on the change of life with its attendant
phenomena. Her instincts and affections remain the same, her sexual
organs continue excitable, her breasts do not wither up, and she is no
less a mother or a wife.[8]
[Footnote 8: _Lessons in Gynæcology_, by Wm. Goodell, M.D., chap.
xxvi.]
Extra-Ovarian Cysts.
There is a class of tumors which, while not ovarian, lie so near to the
ovary as often to involve it, and usually need precisely the same
treatment as cysts of that organ. In their extirpation the ovary is
almost always also involved. This close anatomical relationship makes
it needful to describe them in conjunction with ovarian tumors. They
comprise Cysts of the Parovarium, Cysts of the Oviducts, or Fallopian
Dropsy, and Cysts of the Terminal Vesicle of the Oviduct, often called
the Hydatid or Vesicle of Morgagni.
Cysts of the Parovarium.
These are formed from the dropsical distension of one of the tubules of
the parovarium, or organ of Rosenmüller, which lies between the folds
of the broad ligament and between the ovary and the oviduct. Usually,
one tubule alone is affected, and the cyst is then unilocular; but
exceptional cases have been met with in which several of the tubules
have become dilated, and the cyst is then bilocular or even
multilocular.[9] These cysts are often called cysts of the broad
ligament.
[Footnote 9: "Bursting Cysts of the Abdomen," by Wm. Goodell, _Trans.
American Gynæc. Soc._, 1881, p. 231.]
By examining cysts in their early stage Albert Doran has demonstrated
that "the vertical tubes of the parovarium are lined with epithelium,
sometimes ciliated, but oftener cubical, the original, primitive form
of the tubes of the Wolffian body. From these tubes and from the hilum
of the ovary, full of Wolffian relics, spring the multilocular
papillary cysts which give so much trouble to the operator. At the
outer end of the horizontal tube of the parovarium is a cystic
dilatation which is lined with a structure resembling endothelium.
Apart from the parovarium, between the folds of the broad ligament,
minute cysts are frequent. It is from these and from the terminal cyst
of the parovarium that the simple unilocular so-called parovarian cyst
arises. The terminal cyst of the Fallopian tube never attains a large
size, and no true cysts of the broad ligament appear, when young and
minute, to arise from that tube."[10]
[Footnote 10: _British Med. Journal_, Oct. 21, 1882, p. 792.]
{294} These cysts are more commonly found in young women. From the
thinness of their walls and the limpid character of their fluid, they
yield very marked waves of fluctuation which are equally distinct at
every point. They can usually be distinguished from ovarian cysts
either by a lack of that tenseness so characteristic of the latter or
by varying conditions of tenseness and flaccidity, as if the fluid were
sometimes absorbed more quickly than at other times. They also grow
more slowly than the ovarian cyst, and do not exert the same profound
constitutional impression. The facies ovariana is absent, and the
health of the woman may in no wise be disturbed. They, indeed, in the
majority of cases, seem to do no harm, and are merely annoying from
their bulk. The fluid they contain is with rare exceptions as limpid
and clear as spring-water, but with refractive powers so high as to
magnify the fibres of the wooden pail into which it has been drawn off.
Owing to their very thin walls and delicate structure these cysts on
very slight provocation are liable to burst. On account of the
blandness of the contained fluid this accident is rarely followed by
collapse or by peritonitis. The rent heals up and the cyst usually
refills; but in a large proportion of cases it does not, and the woman
remains permanently healed.[11] Sometimes they are pedunculated, but
often they lie between the two folds of the broad ligament, having no
proper stalk.
[Footnote 11: "Bursting Cysts of the Abdomen," by Wm. Goodell, _Trans.
American Gynæcological Society_, 1881, p. 226.]