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 cases2 rectal enemata or the presence of hardened feces kindled up sexual throbs of the most painful and exhausting character, which thrilled through the whole body for hours at a time.
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 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.