DISEASES OF THE OVARIES.
THERE is an analogy in the reproductive apparatus, running through the
whole animal and vegetable kingdoms. The bulb at the lower extremity of
the pistil of a flower is called the ovary, and it contains the seed,
which in the course of development becomes the fruit.
In the human female, the ovary contains the seed, or germ, which,
becoming fertilized, develops into the human embryo, or the fruit of
conception.
The seeds of the ovaries are termed ova, or eggs, and the organ or
gland in which the germs, or eggs, are prepared is the ovary.
In the human female the ovaries are two follicular glands, about the
shape and size of small almonds, situated on each side of the uterus.
The follicles, or small sacs, of which the ovaries are composed, are
cemented together by delicate fibrillar connective tissue, which is
known as the _stroma_ of the ovary, while the follicle is termed
Graafian vesicle, after the name of its discoverer. Professor Barry,
another investigator, gave the follicles the much better and more
appropriate designation of ovisacs, because each of these capsules or
follicles contains a single ovule, or little egg.
It is carefully estimated that there are 30,000 Graafian follicles or
ovisacs in each ovary, of which only an insignificant number develop
and rupture at each menstrual period. It appears, from the researches
of Valentine and Pflueger, that the Graafian follicles are formed at a
very early period of embryonic life, from a series of minute tubules,
that gradually become constricted from surrounding stroma, at regular
intervals; the ova are subsequently developed in the interior of the
follicles.
Ovarian cysts or tumors cannot be considered in a work for home
treatment, but a desire must be awakened in the minds of thoughtful
readers, to learn the origin of these growths, and it seems to me quite
appropriate at this juncture of the subject, to state that Professor
Waldeyer, of Berlin, has discovered that ovarian tumors are developed
from the remnants of the little tubules from which the Graafian
follicles originate, so that the cause or source of these tumors is
already laid before the patient is born; hence cannot be attributed
to any fault on the part of the afflicted person. From the earliest
period of intra-uterine development up to the age of puberty, the
growth of the ovaries is entirely passive, but after that a continuous
change takes place in the substance of the ovaries; the contents of
the ovaries become active from the period of puberty, from which dates
the commencing aptitude for procreation, until the menopause, or
final cessation of the menses, which, in popular language, is termed
“change of life,” when the aptitude for conception ceases with the
proliferation of the ova.
The period of fruitfulness is characterized by the persistence of the
menses, and this terminates, on the average, in the forty-fifth year;
during all of this time the little ova, or eggs, continually ripen, and
at their maturity the ovisacs, or Graafian vesicles, rupture from an
increased secretion into their cavities. This ripening of an egg and
rupture of a follicle corresponds with the monthly flow. The human ovum
is very small; the largest does not measure above 1-120th of an inch in
diameter, and very often it measures only half that size.
The situation of the ovary is not fixed in the pelvic cavity with
any absolute degree of certainty, but it enjoys a degree of mobility
that is even greater than that of the womb itself, to which it is
attached by means of the ovarian ligament. Its usual place is about an
inch from the uterus and a little backwards. It is partly surrounded
by folds of peritoneum, and partly by the tissue that pads out the
interspaces between the pelvic organs. If we remember the physiological
fact, that at every monthly discharge of blood from the uterus, which
is called menstruation, an ovum or egg ripens and an ovisac bursts,
we cannot fail to appreciate the importance of the intimate relations
that these functions must have, to the health of the individual and the
perpetuation of the species.
This process of ovulation has the peculiarity of the first stages of an
inflammatory action, because the ovaries become congested whenever an
ovisac ruptures.
Through the nervous sympathy existing between the ovaries and uterus,
this too becomes congested, so that the network of uterine vessels
becomes so engorged that the capillary blood vessels of the mucous
membrane of the womb rupture, and the hemorrhage that is the result
constitutes the menstrual flow.
There are three physiological processes concerned in the menstrual
phenomena: first, irritation and congestion of the ovary, rupturing the
ovisac; second, congestion of the Fallopian tubes and uterus; third,
consequent rupture of the blood vessels of the mucous membrane of the
uterus and probably of the Fallopian tubes.
There may be one or more supernumerary ovaries without disturbing the
normal functions; one or both ovaries may be congenitally absent. The
entire absence of both ovaries is generally accompanied by deformities
of so serious a nature that the newly-born infant is incapable of
living.
If the defect is principally limited to congenital absence of the
ovaries, then there is an absence of the changes in which puberty is
recognized; the mammary glands remain flat; there is not the roundness
and fullness of the girl’s figure that signalizes budding maidenhood.
The apparently undeveloped form and girlish characteristics are
prolonged into the years of adult age, and she remains weakly and
small.
In an incomplete or rudimentary development, from an arrested or
imperfect evolution of the ovaries, there is often a condition that
resembles the above very much; neither are these cases nearly so
infrequent as those whose organs are entirely absent. The ovaries may
persist in their fetal state, or their growth may be arrested at any
time before the expected period of puberty. The diagnosis of this
pathological condition must be inferred from the undeveloped state of
the different organs and from the absence of those signs which the
approach of the menses communicate.
Displacements of the ovaries are often the cause of suffering and
disease, that may excite symptoms quite remote from the seat of
trouble. I remember the case of a young woman, who had suffered from
obstinate dyspepsia, which subsided at once after the removal of the
prolapsed ovary. It has been already alluded to, that these glands
are naturally very movable. Anything which increases their weight,
whether inflammatory enlargement or a dragging in connection with
some inflammatory adhesion to a neighboring organ, may cause their
displacement in various directions. It happens that the ovary may form
the contents of a hernia or rupture. A prolapse or descent is the most
common form of an ovarian displacement. We often find one or the other
ovary resting in the pouch between the uterus and rectum, and if the
patient should be troubled with constipation, the hardened feces may
give rise to painful symptoms in the ovaries, and pain in the rectum,
while it also is one of the causes of painful sexual relations. The
irritation to which the dislocated ovary is exposed gives rise to
inflammatory affections, that may be the cause of continual suffering.
INFLAMMATION OF THE OVARIES, OR ACUTE OVARITIS.
What inflammation is elsewhere, it is again here in these glandular
structures.
I endeavored to point out in the beginning of these articles, that the
difference of inflammatory diseases was not due to any difference in
the inflammatory processes, these are identical, but the modification
of the processes are due to the nature of the structure of the tissues
that are involved.
If the intelligent reader will bear this in mind, she will form a clear
idea of all the inflammatory diseases that come under consideration.
Pathological microscopists have recognized two forms of _ovaritis_,
the follicular or parenchymatous, in which the Graafian follicles
or ovisacs are the seat of the inflammatory process, and the
_interstitial_, in which the intervening or interstitial connective
tissue, the _stroma_, between the follicles is inflamed. This
distinction has only a scientific interest because it is impossible to
distinguish one variety from the other in the living subject; this can
only be done with the aid of a powerful microscope after the suspected
ovary is removed from the body. Whether the inflammation is follicular
or interstitial or both combined, it is liable to destroy all the
follicles or ovisacs which contain the ova, that are essential to
procreation, and the consequence will be sterility.
The great functional activity to which the ovaries are subjected at
each menstrual period, make them extremely liable to an inflammatory
process, so that women cannot be too careful of themselves at this
precarious period. It is during menstruation that the ovaries
become periodically congested, and this alone offers an excellent
predisposition for inflammation. As a complication of other
inflammatory diseases, ovaritis is very common; it seems hardly
probable that there can be an inflammation of a pelvic peritoneal fold
or of the pelvic cellular tissue in close proximity to or surrounded
by it, without involving the corresponding ovary. There cannot be a
serious inflammation of the womb or of the Fallopian tubes without
being communicated to the ovaries, and this is always true of the
infectious catarrhs, especially the gonorrhœal form.
There is a great tendency in inflammation of the ovaries to suppurate
and change the entire tissue of the ovary into an abscess. Ovarian
abscesses are not much different in their behavior from abscesses
in the Fallopian tubes or cellular tissue. It is claimed that they
have a greater tendency to break into the bladder than other pelvic
abscesses; this may be due to a displacement of the ovary, which
locates the gland near or between the bladder and uterus, before the
advent of the inflammation. There are no infallible signs that point
to the existence of acute inflammation of the ovaries, owing to the
complication of other inflammatory processes in the majority of cases.
The characteristic pain of an inflamed ovary is of a throbbing or
pulsating nature.
I cannot imagine an ovaritis without at least a circumscribed
peritonitis, and one can hardly suppose a pelvic peritonitis to exist
without in a certain degree compromising the ovary.
If the ovary has once become inflamed, whether alone or as a
complication of other diseases, then the most important question to
decide is the existence of an abscess. This can only be recognized by
an experienced and careful specialist, who has trained his sense of
touch, so that he can feel the abscess between the fingers of one hand
in the vagina, and the other making counter pressure on the abdomen.
The history of each case must in a measure decide the nature of the
fluctuating tumor, whether it may not be an ovarian cyst instead of an
abscess, although an abscess may have been a small cyst.
The development and course of different cases, present various
aspects for consideration. The enlargement may become obstinate to
the ordinary methods of treatment and assume the chronic form of
subacute inflammation. The inflammation may spread from the ovary to
the peritoneal membrane that partly covers it; these are the broad
ligaments of the uterus. This may be the means through which the organ
may grow to the surrounding tissue and adjacent organs, so that it
becomes utterly impossible to move it or even successfully extirpate it
from its intimate attachments.
In other cases the ovary remains entirely free from attachments or
complications, and while it can be generally felt lower down pressing
perhaps on the rectum, it is readily movable or replaced. In the
majority of cases only one ovary is involved, but in these cases
there is a predisposition which in a large proportion sooner or later
compromises also the other ovary in a similar diseased process.
TREATMENT.
The treatment of this affection is greatly modified or influenced by a
knowledge of the causation of the inflammation. In every case, however,
the patient should take to her bed. If there is a profuse vaginal
secretion it should be ascertained if the disease is of infectious
origin, and where this is suspected, the vaginal canal should be
thoroughly rinsed with an antiseptic solution of corrosive chloride of
mercury in the proportion of one grain of the sublimate to two thousand
grains or parts of water, or about fifteen grains to the half gallon
of water. There are tablets to be had at the drug stores which contain
the requisite amount of corrosive when added to a given quantity of
water; these are preferable and more convenient than the crude drug,
and as they are a _deadly poison_ they should be kept under lock and
key. There is nothing to equal the corrosive for an offensive vaginal
discharge, for it is the most reliable disinfectant there is in the
entire pharmacopœa. Half a gallon of this solution should be used at
a time, and after the vaginal canal has been thoroughly disinfected,
about a pint of the same solution must be passed through the uterine
cavity by means of a double catheter, that has a reverse flow and is
especially made for the purpose. To insure against mercurial poisoning
I am in the habit of following mercurial irrigations with warm water,
that was previously sterilized by boiling. One pint of the simple water
is generally sufficient to displace all the mercurial water that might
have remained in the uterine or vaginal cavities. These medicated
irrigations should have an average temperature of 105 degrees Fahr. and
be repeated daily for about a week.
If the vaginal secretion is not of a specific nature, then the Femina
antiseptic uterine lotion is a safer remedy.
Ice bags applied over the regions of the painful ovaries check the
acute inflammation from going into suppuration and forming an abscess.
Should the latter be found to exist, it should be opened by means of a
trocar or aspirator. The bowels should be kept free by taking a daily
dose of Femina laxative tablets.
CHRONIC OVARITIS.
If an acute inflammation does not terminate in prompt recovery or an
abscess it may lose its fiery nature and tone down into a low grade
of prolonged congestion which does not go on to the production of
suppuration. This would constitute the chronic form of inflammation.
It does not follow that all chronic inflammations are preceded by the
acute form, for there are inflammations that are subacute from the
beginning, that is, that there is not the heat nor feverishness in the
tissues which is one of the principal features of the acute process.
Chronic inflammation of the ovaries is much more frequent as an
original or individual affection, than the preceding form. A peculiar
feature of this affection is a gradual growth or enlargement of the
ovary, all the way from a moderate swelling to a good-sized orange.
There has been some discussion as to the particular tissue of the
ovaries that is involved in the inflammatory process, whether it is
the interfollicular structure or the follicules or ovisacs themselves;
practically the solution of this question has no bearing on the
treatment, although it may have an influence on the function of the
organ, which may be more injuriously affected by the latter than the
former variety. The disease occurs almost exclusively after the age of
puberty and during the period of sexual activity. It is not as often
met in the unmarried as in the married, and with the latter it is
more prevalent in the first years of married life. Inordinate sexual
indulgence is a frequent exciting cause, and when this is coupled
with pernicious means that are employed for preventing conception, it
becomes still more frequent.
Chronic inflammation of the vagina, womb, and of the Fallopian tubes is
often transferred to the ovaries.
The infectious catarrh to which the genital tract of the female is more
or less exposed from a lack of proper cleanliness of her own person,
or a gonorrhœal infection from her male companion, show a peculiar
tendency to gradually spread the inflammatory processes to the ovaries.
Some careful observation has established the fact that an apparently
cured gonorrhœal infection in the male may, after a year or two, excite
a gonorrhœal catarrh in the genitals of the female; a great many
diseases of the ovaries have been traced to this source of infection.
As gonorrhœa is not an uncommon affection among the male portion of
the community, it is not sufficient for the intelligent members of the
medical profession to know of these dangers of infection, but every man
and woman should be apprised of the great danger there is of infecting
the marital chamber with the pollution of the brothel.
The symptoms of chronic ovaritis are more or less dependent on the
causation of each individual case.
Sometimes it is traced to the fiery stage of the acute affection,
while in other instances it can be laid to some indiscretion during
the menstrual flow, then, again, it may have developed itself so
stealthily that the greatest acumen and skill are required to detect
its origin. The most important and constant sign is a steady pain in
one or both ovaries. When this pain is violent, it shoots toward the
back and rectum and down the thighs. The pain becomes heightened from
an accumulation of feces in the rectum, which a habitual constipation
entails. Marital excesses near the approach of the menstrual period
or shortly after the disappearance of the menses are quite likely
to precipitate the painful symptoms. The bladder sympathizes in a
certain proportion of cases, so that there is a frequent desire to pass
water. In the course of time the distressful symptoms that have been
enumerated derange the digestive apparatus; the patients lose their
appetite and decline into a debilitated and nervous state, so that one
or the other hysterical phenomenon become more or less prominent in
persons of a nervous temperament.
Sterility is a rule with this class of women, even if there is only one
ovary affected; this would indicate that the apparently healthy one
sympathizes with the other, or an accompanying catarrh of the uterus or
tubes may prevent the passage of the fertilizing germ. If both ovaries
are inflamed, then it is quite natural to suppose that the delicate
follicles and their contents, the ova, become destroyed or so altered
that they no longer answer the purpose of reproduction. It is seldom
that one meets a chronic ovaritis without a uterine catarrh, and how
much this contributes to the sterility is not easy to tell.
TREATMENT.
The course of this affection in the majority of cases is favorable. If
the treatment is intelligently administered, the pain and congestion
gradually subside, and as this class of patients have generally learned
from sad experience that negligence or indiscretion on their part will
excite a relapse, they soon learn to avoid these, so that they enjoy
comparative immunity from suffering for a considerable length of time.
There is a smaller proportion of cases whose unfortunate surroundings
or lack of intelligence makes remedial measures of no avail. These poor
women have neither respite from physical labor nor freedom from the
animal passions of their husbands, and thus living in constant pain
they become drooped in spirit and reduced in vigor, so that they fall
an easy victim to any intercurrent affection that may attack them.
In proportion as the patients can give their diseased ovaries freedom
from irritating influences are the chances for their complete recovery
increased.
To accomplish this object, quietude in the recumbent posture, sexual
abstinence and a free daily stool form the basis for recovery. If there
is much pelvic pain, this is best controlled by means of the ice bag,
4x6 inches in size, of which one on each side, wrapped in one thickness
of flannel, should be applied to the groin or region of the ovaries;
cold-water compresses, thoroughly wrung, so as not to drip, and covered
with flannel so as to keep the bed covering dry, are also advisable,
but only a poor substitute for the ice.
Iodoform suppositories greatly stimulate the absorption of the
inflammatory exudation; one of these should be introduced into the
vaginal canal each day. If the patient can get up without any painful
symptoms, she should take the hot sitz bath for ten or fifteen minutes
daily, and as a general tonic, this is a useful prescription.
NO. XI.
Take: Bromide of sodium 2 drams
Iodide of potassium 1 dram
Comp. tinct. of gentian 2 ounces
Water, sufficient to make 8 ounces
Mix. A tablespoonful three times a day.
There is no affection in the entire category of diseases of women, in
which the confidence of women has been more abused by specialists,
than by meddlesome surgical invasions, for the extirpation of one or
both ovaries, to cure real or imaginary diseases of these glands.
There is a veritable mania among surgeons for this operation, but the
conservative portion of the profession are awakening to a conviction
that this is entirely wrong, and a presumption on professional license
that is altogether unpardonable.
If these castrations were confined to the removal of ovaries that are
unmistakably degenerated or diseased, and that had resisted intelligent
treatment for some time, there would not be the same objection, but
when ovaries are removed that are apparently healthy, but through
ignorance or incompetency are supposed to be the offending members,
then, I say, that is an outrage.
There are a great many women who have been subjected to the dangers of
a so-called normal ovariotomy, without being in the least benefited by
the operation. The symptoms which the extirpation of their ovaries was
to relieve, persisted as before, and they discovered, when it was too
late, that spaying is not a panacea for the ills that suffering women
are heir to.
The ovaries are in delicate sympathy with all the other pelvic organs,
and when these are affected there may be more or less pain in one
or both of these glands. They may be even the seat of a neuralgic
affection without any structural change in the organ or in the
neighboring organs. This would be simply a reflex sign of a general
debilitated condition, and to mistake all these for ovarian disease and
to make it an excuse for their removal, is not warranted by careful
observation. Electricity is now coming to the front as one of the most
valuable remedies for just this class of affections, and I will give
a detailed account of the nature of this remedy and the requirements
for its successful application, which persons who speak lightly of its
virtue, never acquire nor take the pains to possess.