CHAPTER XXVIII.

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 bi

manual 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 kneechest 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 The enlarged ovary diminishes in size and weight, and its ligaments contract and regain tonicity.

cure.

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 oophorectomy 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 un