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.
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.
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.”
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.