Fig. 154.—A tubercular pyosalpinx. To the left are three calcified plates that were found in the tube.
Fig. 154.—A tubercular pyosalpinx. To the left are three calcified plates that were found in the tube.
Tuberculosis of the peritoneum is an indication for, rather than a contraindication to, the operation. The most extensive cases of peritoneal tuberculosis have been cured by opening and draining the abdomen. If the tubes are rendered inaccessible from the involvement of surrounding structures, the operator must content himself with opening and draining the abdomen.
Adenomaof the Fallopian tube is a rare disease; but a few cases have been described in medical records. The presence of primary adenoma in the Fallopian tube is strong proof of the glandular character of the mucous membrane—an anatomical point which, as has already been said, has been denied by some writers. In adenoma the tube becomes distended with the typical adenomatous mass, which may protrude from the abdominal ostium.
In some of the reported cases there has been found a considerable quantity of free fluid in the peritoneum, though the peritoneum itself was not diseased. It seems probable that this secretion originated in the tube and escaped at the ostium.
Myoma.—Notwithstanding the frequency of myomatous tumors of the uterus, the condition is exceedingly rare in the Fallopian tubes. The tumors originate in the muscular coat, and are usually so small as to create no disturbance.
Cancer.—Primary cancer of the Fallopian tubes is an extremely rare disease. A very few isolated cases have been reported.
Cancer of the tubes secondary to cancer of the body of the uterus occurs more frequently.
Sarcomaof the tube is a very rare disease.
Actinomycosisof the Fallopian tubes has been described.
Syphilitic gummataoccasionally attack the Fallopian tube in women who are the victims of constitutional syphilis.
The diagnosis of these unusual lesions of the Fallopian tubes is impossible with our present knowledge. The conditions have usually been found post-mortem or have been unexpectedly discovered at operation. The subjective symptoms throw no light upon the subject of differential diagnosis. Examination reveals merely a tubal tumor.
As the rule is to operate in all cases of tubal tumor, the proper treatment will probably be applied, notwithstanding the uncertainty or mistake of diagnosis.
Tubal pregnancy occurs when a fecundated ovum is developed in the Fallopian tube.
Fecundation may take place in the Fallopian tube, because spermatozoa may pass through the uterus and the tube into the pelvic cavity; but unless something occurs to arrest the passage of the fertilized ovum into the uterus, a normal uterine pregnancy will result. It is said by Webster that predisposition to tubal pregnancy is due to a “developmental fault, whereby there is reversion, either of structure or reaction tendency, in the tubal mucosa to an earlier type in mammalian evolution.”
In other words, decidual changes, following the fertilization of the ovum, may in some women occur in the mucous membrane of the Fallopian tubes as well as in that of the uterus. If this condition is present in any case, and at the same time something occurs to impede the passage of the ovum into the uterus, a tubal pregnancy may take place.
Interference with the passage of the ovum along the tube has been attributed to a variety of causes. Chronic salpingitis is a frequent cause. It destroys the cilia of the epithelial cells of the tubal mucosa. It produces thickening of the tubal walls, and causes peritoneal adhesions that impede the normal peristaltic action of the tube.
Obstruction to the passage of the ovum may also be caused by polypi or tumors of the tube; by tumors external to the tube pressing upon it; by displacement and hernia of the tube; by diverticula of the tube; or by abnormal foldings of the tubal wall. Tubal pregnancy hasoccurred in tubes in which no lesions whatever could be discovered by the most careful examination.
It seems probable that practically all pregnancies that occur outside of the uterus originate in the Fallopian tube.
Pregnancy may occur in any part of the tube from the abdominal ostium to the uterus.
Tubal pregnancy is said to be infundibular when gestation begins in the infundibulum or in an accessory tube-ending. This variety has also been called tubo-ovarian, because in time the gestation-sac may become adherent to the ovary and be bounded by both tube and ovary.
Fig. 155.—Tubal pregnancy, removed before rupture. The opening that has been cut in the tube shows the chorionic villi.
Fig. 155.—Tubal pregnancy, removed before rupture. The opening that has been cut in the tube shows the chorionic villi.
The pregnancy is said to be ampullar when gestation begins in the ampulla of the tube. This is the most usual seat of tubal pregnancy. It is called interstitial when gestation begins in the interstitial portion, or that part of the tube in immediate relationship with the uterus.
Changes in the Fallopian Tube.—During the early stages of tubal pregnancy—the first two or three months—itseems probable that a certain amount of hypertrophy and hyperplasia of the muscular wall of the tube takes place. The general form of the tube is spindle-shaped (Fig. 155). There is a marked increase in the vascularity of the tube, most pronounced in the neighborhood of the ovum. The whole tube becomes turgid and swollen. The peritoneal margin or ring surrounding the ostium abdominale becomes prominent, and gradually, as has already been described under Salpingitis, projects beyond the fimbriæ, contracts, and ultimately hermetically closes the ostium.
Inflammation of the peritoneal covering of the tube may be present. Such inflammation may have preceded the tubal pregnancy or may have occurred as the result of the pregnancy. It produces various tubal adhesions and distortions, and may still more firmly close the abdominal ostium. The changes that take place in the mucous membrane of the tube and in the developing ovum are similar to those that occur in the uterus in a normal pregnancy.
A variety of terminations occur in tubal pregnancy:
I. In very exceptional cases the pregnancy may continue until full term, without rupture of the tube taking place.
II. The tube may rupture. This is by far the most usual occurrence. The rupture may take place into the broad ligament, into the peritoneal cavity, or, in the case of interstitial tubal pregnancy, into the uterus.
III. Tubal abortion may occur, the ovum being discharged through the abdominal ostium into the peritoneal cavity.
IV. The ovum may be destroyed in the tube, gestation being stopped before rupture takes place.
Rupture of the tube is the rule in tubal pregnancy. The time of rupture depends upon the position of the ovum in the tube. It occurs somewhat later in the interstitial variety than when the ovum is situated in the free portion of the tube. Rupture in interstitial pregnancycommonly occurs before the fifth month. In the other forms of tubal pregnancy it occurs most usually before the end of the third month. In the latter class of cases the greatest number of ruptures occur during the second month.
Rupture is caused by the gradual thinning of the tube from distention. Rupture may take place suddenly, a large hole, through which the ovum escapes, being produced; or the rupture and discharge of the ovum may take place gradually without causing any acute symptoms.
When the rupture takes place between the layers of the broad ligament, the hemorrhage is usually not very profuse, as it is controlled by pressure of the structures that surround the blood. A broad-ligament hematoma is formed. The ovum may be destroyed as a result of the rupture, and no further lesions due to the development of gestation will arise. The hematoma, with the ovum, may in time be absorbed; or suppuration may occur, with the production of a pelvic abscess; or mummification, adipoceration, or lithopedion formation may take place in the fetus.
If the ovum is not destroyed by the rupture, it may continue to develop in the cavity formed by the tube and the broad ligament. The placenta may remain attached to the inner surface of the tube, or it may contract adventitious attachments to any of the surrounding structures—the surface of the uterus and the pelvic floor. The cavity occupied by the ovum may continue to enlarge, by the pushing aside of pelvic and abdominal organs, until full term is reached and spurious labor comes on.
In some cases a secondary rupture of the gestation-sac occurs, and the fetus is discharged into the peritoneal cavity.
When rupture of the tube into the peritoneal cavity occurs, the danger of fatal hemorrhage is very great. The majority of women die within forty-eight hours after this accident, unless relieved by immediate laparotomy.There is no surrounding pressure to control the hemorrhage, as in the case of rupture into the broad ligament. Sometimes the escaping ovum plugs the rent in the tube, and bleeding is checked in this way.
If the woman survive the effects of hemorrhage, she may die from peritonitis or from suppuration of the hematocele in the peritoneal cavity.
In exceptional cases, if the pregnancy be early, the blood and the ovum may be absorbed by the peritoneum, and spontaneous recovery occurs.
If the woman is not destroyed by the first effects of the rupture, the fetus, surrounded by its membranes, may escape into the peritoneal cavity, while the placenta may remain attached to the tube and gestation may continue. It is very doubtful whether the fetus will continue to live if it escapes into the peritoneum free of the membranes. There is no evidence that an early ovum may escape into the cavity of the abdomen and develop on the peritoneum.
If the fetus does not survive, it may be absorbed by the peritoneum or mummification may occur.
Tubal abortionmeans the separation of the ovum from the tube-wall, and its partial or complete discharge through the ostium abdominale into the peritoneal cavity. The accident is accompanied by hemorrhage into the tube and thence into the peritoneal cavity.
Tubal abortion is most likely to occur during the early weeks of pregnancy (the first and the second months), before the abdominal ostium has become closed.
It is probable that tubal abortion is much more frequent than is generally supposed. According to Sutton, tubal abortion was probably the cause of the peritoneal hematocele in many cases in which the bleeding was attributed to other origin, as reflux of menstrual blood from the uterus and simple hemorrhage from the tube.
In tubal abortion the loss of blood into the peritoneum may be so great that the woman is destroyed. In other cases death results from peritonitis and suppuration ofthe hematocele. And, finally, in a good many cases the blood and ovum may be absorbed, and recovery takes place. Sometimes, at operation, the ovum is found in the peritoneal cavity without any blood. The blood had either been small in amount and quickly absorbed, or there had been no escape of blood into the peritoneum. Blood-clot is usually found in the Fallopian tube after tubal abortion. The ostium may become closed and a hematosalpinx may result.
Fig. 156.—Extra-uterine pregnancy; tubal abortion. The bleeding is checked by a large coagulum distending and thinning out the tube; the fimbriated opening is greatly distended, but the greater diameter of the clot in the ampulla prevents its escape. Wall of tube averaging 1 millimeter in thickness. Operation. Recovery, July 7, 1896. Natural size. (Kelly. Copyright, 1898, by D. Appleton & Co.)
Fig. 156.—Extra-uterine pregnancy; tubal abortion. The bleeding is checked by a large coagulum distending and thinning out the tube; the fimbriated opening is greatly distended, but the greater diameter of the clot in the ampulla prevents its escape. Wall of tube averaging 1 millimeter in thickness. Operation. Recovery, July 7, 1896. Natural size. (Kelly. Copyright, 1898, by D. Appleton & Co.)
Fig. 157.—Coagulum turned out, showing a cast of the tube extending up into the isthmus. On its surface lies the fetus. Natural size. (Kelly. Copyright. 1808, by D. Appleton & Co.)
Fig. 157.—Coagulum turned out, showing a cast of the tube extending up into the isthmus. On its surface lies the fetus. Natural size. (Kelly. Copyright. 1808, by D. Appleton & Co.)
When the ovum is destroyed in the tube before rupture takes place, the fetus and the blood may be absorbed; or mummification, adipoceration, or lithopedion-formation may result; or suppuration may occur, with the formation of a pyosalpinx; or, if death of the fetus happens in the early weeks, the tube may be found closed at the ostium abdominale, and filled with blood in which no fetus may be detected. Such cases have been repeatedly described as hematosalpinx, the real origin of the condition in pregnancy not being known. The fetus had been absorbed or broken up and scattered through the blood-mass. Careful microscopic examination of the tube reveals the true condition—a destroyed tubal pregnancy with hemorrhage into the tube. As has already been said, hematosalpinx not caused by tubal pregnancy is very rare.
Coincidently with the development of the tubal pregnancy there occur enlargement of the body of the uterus and decidual transformation of the endometrium. The decidual membrane separates, entire or in fragments, and is discharged from the uterus, after the death of the embryo or during its development, from the eighth to the tenth week. The decidua again forms only when gestation continues undisturbed.
The enlargement of the uterus varies a great deal according to the position of the tubal pregnancy and the course of its development. The interstitial variety is accompanied by the greatest uterine enlargement. Whenthe tubal gestation has reached full time the uterus may measure from 4 to 7½ inches in length.
The increased size of the uterus is most marked in the long diameter. The change of shape does not resemble that which occurs in normal pregnancy.
The uterus also becomes softer in tubal pregnancy, and the cervix softens somewhat, though not so much as in a uterine pregnancy.
If the woman and the fetus survive the many dangers that accompany the progress of tubal gestation, the development of the fetus will go on to full term, and then the phenomenon of spurious labor will come on.
In spurious labor there are a series of periodical pains that resemble those of normal labor. The pains may last from a few hours to several days. They may cease, and reappear after varying intervals.
Hemorrhage usually takes place from the uterus. After the spurious labor the uterine discharge may be of the same character as that seen after normal labor.
It is probable that the fetus always dies after spurious labor. The liquor amnii is absorbed, the gestation-sac shrinks, and changes take place in the fetus similar to those already referred to. It may become mummified or converted into adipocere or a lithopedion. In this condition it may remain in the abdomen for many years. A mummified fetus that had been carried for fifty years has been removed post-mortem from a woman aged eighty-two.
Rarely, after spurious labor the gestation-sac ruptures and the fetus is discharged into the peritoneum, the vagina, or the large intestine, whence it is born through the anus.
Thesymptomsof tubal pregnancy are in some cases similar in all respects to those of normal uterine pregnancy. In extremely rare cases the woman has reached full term in ignorance of any unusual condition. Usually, however, the early occurrence of some of the accidents of tubal gestation attracts her attention. Before suchaccidents or complications arise there are most frequently no subjective symptoms to excite any suspicion of the peculiar form of pregnancy. Changes in the skin, in the nipples, in the nervous and circulatory systems, and in the gastro-intestinal tract may resemble those of normal pregnancy, and are subject to the same variations.
Mammary changes accompanied by the secretion of milk occur in tubal pregnancy. These changes are, however, less pronounced than in uterine gestation. The vagina may undergo changes similar to those of normal pregnancy; it becomes soft, relaxed, and altered in color, and pulsation of vessels may be felt in the walls.
It should always be remembered, however, that tubal pregnancy may occur without the presence of any of the signs of pregnancy. Women in perfect health, thoughtless of pregnancy, have died of acute hemorrhage from a ruptured tubal gestation—the first symptom of this condition.
The changes in menstruation vary a great deal. Menstruation usually ceases when tubal pregnancy begins, though not with the same regularity as in normal pregnancy.
Sometimes menstruation continues for a few months and then ceases. In other cases menstruation is arrested for the first few months, and occurs with greater or less regularity during the latter months of pregnancy. There may be an irregular discharge of blood throughout the whole course of gestation.
In the blood discharged from the uterus there may often be found pieces of decidual tissue of various size. Sometimes the whole decidual membrane of the uterus may be expelled in one mass. In any suspected case the blood should always be carefully examined for such decidual membrane. All shreds of tissue should be submitted to careful microscopic examination. The woman should be questioned in regard to the passage of such tissue before she came under medical supervision.
The woman often complains of periodical pains occurringin the hypogastrium and in the pregnant tube. They usually appear after the second month, though they may begin earlier. These pains are thought to be caused by the contractions of the uterus and the gestation-sac.
The abdominal enlargement in extra-uterine pregnancy differs in several respects from that of normal pregnancy. It is usually most marked on one side of the abdomen, especially during the first five or six months.
Toward the end of gestation the enlargement becomes more symmetrical in the abdomen, and resembles closely that of normal pregnancy.
In tubal gestation, on account of the higher position of the tube, bulging of the abdominal wall is likely to appear somewhat earlier than in normal pregnancy. The abdominal enlargement in tubal pregnancy does not follow the same uniform progress that is characteristic of uterine pregnancy.
Fetal movements take place, and fetal heart-sounds are heard as in normal pregnancy.
Bimanual examination made before rupture of the tube will reveal the tubal enlargement, the shape of the tube depending, of course, upon the position of the tubal pregnancy. The tubal enlargement is said by Veit to have a characteristic soft feel, distinct from the hard or fluctuating enlargements of other forms of tubal disease.
After rupture the distinct tubal tumor disappears, and the examiner feels a mass lying to one side of or behind the uterus. The enlarged tube may be felt merged in this mass.
If pregnancy continues after rupture, the fetal movements may be felt and ballottement may be obtained. The cervix is found to be somewhat softened; the os may be patulous; the uterus is soft and enlarged. The uterine enlargement, however, is not of the same rounded shape as the pregnant uterus, and the size is much less than that of corresponding periods of normal pregnancy.
It is of great importance to study the symptoms of the accidents of tubal pregnancy. As has already been said,it is usually the accident of rupture that first directs the woman’s attention to the abnormal condition.
The symptoms depend upon the seat of rupture. Rupture of the tube into the broad ligament is a much less serious accident than rupture into the peritoneal cavity.
If the rupture into the broad ligament is sudden, the woman complains of sudden acute pain in the affected side. The pain may extend to the back and throughout the pelvis. The intensity and extent of the pain depend on the amount of blood that escapes. Sometimes only a small hematoma is found in the broad ligament; at other times the blood burrows around the rectum, and symptoms of pressure may arise. Difficult defecation may follow. Retention of urine may occur.
The woman suffers from shock, and may become somewhat anemic.
Bimanual examination reveals the condition. The broad ligament will be found filled with a tense mass that bulges into the vagina. The uterus is pushed to one side. The mass may extend behind the uterus and surround the rectum. The upper outlines felt by the abdominal hand are ill defined.
The loss of blood from simple rupture into the broad ligament is not often sufficient to cause death. The fetus may continue to develop, however, and secondary rupture into the peritoneal cavity may occur.
Rupture of the tube or of the gestation-sac into the peritoneal cavity is a very fatal occurrence. In the majority of cases death from hemorrhage occurs within twenty-four hours.
Unless the ovum plugs the rent in the tube, there is nothing to arrest the hemorrhage.
The woman is seized with sudden pain in the side, often described as the sensation of “something giving away.” She suffers from faintness, acute anemia, nausea, vomiting, and collapse. As in other cases of acute anemia, there may be delirium and convulsions.
Bimanual examination made after intraperitoneal rupturereveals an indefinite fulness or a yielding mass in the pelvis behind the uterus. The blood free in the peritoneal cavity coagulates slowly, and the fluid blood or soft unrestrained clots are often very difficult to palpate. For this reason, at first the examiner can feel only an ill-defined fulness in the pelvis. If the woman survives and the mass of blood becomes more solid, it may then be distinctly palpated as a solid mass behind the uterus, bulging into the vagina, and extending up into the abdomen. Though the hematocele may at first be difficult to define, yet the enlarged tube may usually be palpated, and the ovum may sometimes be felt in the midst of the ill-defined mass of blood.
As has already been said, in rare cases rupture may occur intraperitoneally or into the broad ligament without producing any of the severe symptoms just described. The fetus continues to develop, and the woman will be ignorant that rupture has ever occurred. Between the two extremes there are all degrees of severity.
In tubal abortion the symptoms resemble those of intraperitoneal rupture.
If the fetus dies within the tube, the symptoms become those of hematosalpinx or other form of tubal disease.
Diagnosis.—The diagnosis of tubal pregnancy is not often made before rupture, because there are usually no symptoms that direct the woman’s attention to the abnormality of her condition. Very often she thinks that she is normally pregnant.
If opportunity is given for examination before rupture, the diagnosis may sometimes be made. The woman presents the signs of pregnancy. The uterus may be slightly enlarged, though not of the size or shape normal for the stage of pregnancy. There is a soft tubal tumor.
Immediately after rupture the diagnosis of the condition must be made from a study of the previous history,from the present subjective symptoms, and by bimanual examination.
If a woman who had thought herself pregnant is suddenly seized with pain in the side, followed by anemia and shock, the suspicion of extra-uterine pregnancy should be aroused. If bimanual examination reveals the hematoma or hematocele in the pelvis, with tubal enlargement, the diagnosis may be made. Pelvic hematoma and hematocele are in nearly all cases caused by tubal pregnancy.
If the woman survives the rupture and the fetus continues to develop, the diagnosis becomes easier the more advanced is the case.
It must be remembered that amenorrhea is not as general in tubal as in uterine pregnancy. The woman often gives the history of irregular bleeding, or of arrest for a few periods and then recurrence of menstruation. Such experience may lead her to seek medical advice even before rupture.
The intermitting attacks of pain that are sometimes felt in the affected tube may also cause her to seek medical advice.
A history of the discharge of membrane or of shreds of membrane is of great value. If opportunity is afforded for examination of such shreds, and decidual cells are found, and if uterine pregnancy may be excluded, there is very strong evidence that any mass in the pelvis is an extra-uterine gestation.
It has been advised to curette the uterus for diagnosis in order to determine the decidual character of the lining membrane. This is good advice if the operation is performed with great care and if we can with certainty exclude the possibility of uterine pregnancy. If followed indiscriminately, numbers of abortions would be produced. Uterine pregnancy has often been mistaken for tubal pregnancy. The mistake is likely to occur when the fundus is drawn to one side or is retroflexed. Uterinepregnancy may occur with tubal enlargement from other cause than tubal pregnancy.
In conclusion, the diagnosis of tubal pregnancy before the presence of a fetus can be ascertained is based on the following considerations: The symptoms of pregnancy; a tubal or pelvic tumor; a slightly enlarged though not pregnant uterus; discharge of decidual tissue from the uterus; the history of the woman pointing to menstrual irregularity, uterine discharge of shreds, history of previous tubal rupture.
Treatment.—The treatment of tubal pregnancy is operative. It may be considered under the following heads: Before primary rupture; At the time of rupture; After rupture.
Before Primary Rupture.—If the physician is so fortunate as to recognize a tubal pregnancy before primary rupture, he should without delay remove the affected tube and the contained ovum. The operation is simple, is attended by no more danger than that accompanying an ordinary salpingo-oöphorectomy, and the woman is saved the imminent dangers associated with a developing tubal pregnancy. There are no circumstances under which it is proper to follow an expectant treatment.
Most of the cases of unruptured tubal pregnancy that have been operated upon were not recognized until the abdomen had been opened. The operation was performed under the diagnosis of pyosalpinx, hematosalpinx, or some other tubal disease. The cases show the value of the general rule to operate without delay for all gross diseases of the tubes.
At the Time of Rupture.—Many cases of tubal pregnancy are first seen at the time of rupture. In such cases celiotomy should be performed without delay. The condition is most urgent in intraperitoneal rupture, but it is the safest rule to operate immediately, whether the rupture be intraperitoneal or extraperitoneal. It is unwise to wait for reaction. The physical depression in such cases is due more to hemorrhage than to shock, and it isin accord with general surgical principles to arrest hemorrhage at once.
Rupture usually takes place before the twelfth week, and the whole product of conception, with the tube, may readily be removed. Hemorrhage usually ceases as soon as the proximal and distal ends of the ovarian artery are ligated. The ligatures may be placed about the ovarian artery, at the pelvic wall, and at the uterine cornu, as the first steps of the operation, before any attempt is made to remove the mass. It may be necessary to close the rent in the broad ligament by a series of sutures.
After Rupture.—If the woman survive, and is first seen after primary rupture, one of two conditions will be present—a destroyed or a developing extra-uterine pregnancy. If the fetus has died and gestation has ceased, the woman is exposed to the various dangers that attend the presence of such a foreign body in the abdomen. If the fetus has died during the earlier months, it may have been absorbed and spontaneous cure may take place. Even a dead full-term fetus has been carried in the abdomen for years without producing a fatal result to the mother. It seems safest, however, in all such cases to operate as soon as the condition is recognized. The rules of abdominal and pelvic surgery apply to such cases. The placenta of a dead fetus may be removed without fear of uncontrollable hemorrhage.
If the woman is seen after primary rupture, with a developing gestation, the case presents much more serious dangers. These dangers lie in the placenta. If the pregnancy has not advanced beyond the fourth month, it is usually possible to remove the whole of the gestation-sac, the embryo, and the placenta without uncontrollable hemorrhage. The ovarian, and if necessary the uterine, arteries may be ligated, and the placenta may be removed in one mass. The cavity of the broad ligament may be obliterated by buried sutures.
If the gestation has advanced beyond the fourth month, it is often impossible to remove the placenta without fatalhemorrhage. Many women have bled to death from the attempt. The operator sometimes incises the placenta as he enters the gestation-sac, and is obliged to proceed with its removal. In other cases he starts to remove it, and finds, too late, that the hemorrhage is beyond his control. In the advanced months of pregnancy the sac and the placenta may become adherent to any of the abdominal or pelvic viscera and to the large vessels. Hemorrhage cannot be controlled, as in the earlier months, by ligation of the ovarian and uterine arteries. The result in these cases is determined by the ability of the operator. A full-term living child, the whole sac, and the placenta have been successfully removed. If the attachments are such that the surgeon considers it unsafe to attempt the removal of the sac and the placenta, the sac should be incised and the fetus should be removed, the cord being divided between two ligatures; the sac should be sutured to the abdominal incision; the cord should be drawn through the opening, and the sac packed with gauze. At the end of four or five days the gauze pack may be removed, under anesthesia if necessary, and the placenta may be taken away. There is very much less risk of hemorrhage after the lapse of a few days. Some operators prefer to allow the placenta to come away spontaneously. This is sometimes necessary.
It will be seen, from this consideration, that the treatment of all varieties of ectopic gestation is operative, and that the sooner the operation is performed the better for the patient. Consideration for the life of the child should have no influence in determining the time of operation.
Ovarian Pregnancy.—The possibility of the implantation and development of the fertilized ovum in the Graafian follicle has been denied by many authorities. It seems probable, however, that such a form of pregnancy does very rarely occur. The cause of ovarian pregnancy is thought to be due to some disturbance of the normal process of ovulation, whereby the ovum fails to leave the ruptured follicle and is there fertilized and developed.
Anatomy.—The ovaries vary a good deal in size, within the limits of health, in different individuals. It is unusual to find the two ovaries in the same person exactly alike in size, shape, and appearance.
Fig. 158.—Uterus, tube, and ovary of a child one month old (Sutton).
Fig. 158.—Uterus, tube, and ovary of a child one month old (Sutton).
The size, shape, and appearance of the ovary change at the different periods of life. In the new-born child the ovary is elongated and lies parallel to the Fallopian tube (Fig. 158). In rare cases this infantile shape of the ovary may persist throughout life.
The general shape of the mature ovary is oval. The average measurements are—long axis, 3 to 5 centimeters; breadth, 2 to 3 centimeters; thickness, 12 millimeters; weight, 100 grains. These measurements are subject to great variations. Henning’s table of measurements shows that the ovary of the multipara is no larger than that of the virgin.
After the menopause the ovaries shrink a great deal in size, sharing in the general atrophy of all the reproductive organs. The ovary of an old woman may weigh but 15 grains.
The healthy ovary is of a pinkish pearly color. On its surface are seen small bluish areas that mark the position of unruptured or of recently ruptured ovarian follicles. The ripening follicles project somewhat from the surface of the ovary, and the old ruptured follicles are marked byscars which in time cover and render irregular the whole surface of the ovary (Fig. 159).
The surface of the ovary becomes more irregular and wrinkled after the menopause. The follicles disappear, until finally nothing is left but a mass of fibrous tissue and a few blood-vessels.
The ovary lies in the posterior layer of the broad ligament. It is attached by this connection with the broad ligament and by the ovarian and infundibulo-pelvic ligaments.
Fig. 159.—Ovary (natural size), with the Fallopian tube in relative position (Sutton).
Fig. 159.—Ovary (natural size), with the Fallopian tube in relative position (Sutton).
The ovarian ligament extends from the inner end of the ovary to the angle of the uterus immediately below the origin of the Fallopian tube. This ligament varies in length from 3 to 5 centimeters. It is shortest in the virgin, and longest in the multiparous woman. The ligament consists of a fold of peritoneum containing unstriped muscular fiber from the uterus.
The infundibulo-pelvic ligament is that part of theupper margin of the broad ligament lying between the distal end of the Fallopian tube and the pelvic wall. It is about 2 centimeters in length. The length is greatest in the multiparous woman.
The position of the ovary is maintained by its attachments and by its own specific gravity. The considerations that have been discussed in regard to the position of the uterus also apply here.
The blood-vessels are the utero-ovarian arteries and the ovarian arteries and veins. The ovarian artery is homologous to the spermatic artery in the male. The course of the ovarian veins has an important influence upon some pathological conditions of the ovaries.
Fig. 160.—View of the posterior surface of the uterus, Fallopian tubes, ovaries, and broad ligaments. The infundibulo-pelvic ligament is shown on the left (Dickinson).
Fig. 160.—View of the posterior surface of the uterus, Fallopian tubes, ovaries, and broad ligaments. The infundibulo-pelvic ligament is shown on the left (Dickinson).
The right ovarian vein enters the inferior vena cava at an acute angle, and at the junction of the two there is a very perfect valve.
The left ovarian vein enters the left renal vein at a right angle: there is no valve on this side. This anatomical difference affords a probable explanation of the greater tendency to congestion and prolapse of the left ovary.
The ovary is composed of connective tissue which surrounds the Graafian follicles, blood-vessels, lymphatics, nerves, and unstriped muscular fibers. The posterior portion, or the free portion of the ovary, is covered with the germinal epithelium, or modified peritoneum, which is continuous with the peritoneum of the broad ligament.
The ovary is divided into two portions, which present distinct anatomical, physiological, and pathological differences.
Theoöphoronis the egg-bearing portion of the ovary. It corresponds to the free border of the gland.
Theparoöphoroncorresponds to the hilum of the ovary—that portion in relation with the broad ligament.
The paroöphoron contains no ovarian follicles. It is composed of connective tissue and numerous blood-vessels. In the paroöphoron of young ovaries remnants of gland-tubules—vestiges of the Wolffian body—may be found.
Accessory ovarieshave been described by several writers, and their existence has often been assumed to account for the persistence of menstruation after a supposed complete salpingo-oöphorectomy. It is very doubtful if a true accessory ovary has ever been found. Bland Sutton says: “As the evidence at present stands, an accessory ovary quite separate from the main gland, so as to form a distinct organ, has yet to be described by a competent observer.” It is probable that the bodies that have been described as accessory ovaries have been more or less detached portions of a lobulated ovary, or small fibro-myomatous tumors of the ovarian ligament. Abdominal surgeons have had opportunity of examining thousands of ovaries at operation, and yet I know of no one who has come across a third 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.
Thediagnosisof hernia of the ovary is made from palpation of the gland; from the determination, by bimanualexamination, 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.
Thetreatmentis 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 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 variouscausesof 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 maycause 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 thencethroughout 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 andprolapse 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 unlessthe 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.
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 beparenchymatous; when the connective tissue is chiefly affected, it is calledinterstitial 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, orone 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 usualcauseof 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.
Thesymptomsof 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 inflictingunnecessary 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.