CHAPTER XXV.

"How frequently have authors noticed the numerous morbid lesions of the ovaries! But of what avails such information if they do not describe their causes ?-KRUger.

CAUSES OF SUB-ACUTE OVARITIS.

I SHALL investigate at considerable length the causes of subacute ovaritis, so as to preclude the necessity of recurring to them when describing the acute form. The causes of both diseases are the same, different effects being produced by the difference of their intensity and the variety of their combinations; besides, as the ovaries give to woman all her female attributes, by an acquaintance with the causes of ovaritis, those of the diseases of women in general become known. The causes of sub-acute ovaritis are, like those of other diseases, predisposing and exciting.

PREDISPOSING CAUSES.

The principal predisposing cause is to be found in the nature and functions of the genital organs; for although in woman the ovary is, anatomically speaking, separated from the oviducts, excepting during the first few months of fœtal life, in a physiological point of view the generative intestine is one in woman, as it is so anatomically in many of the lower animals; for whenever these organs are called into functional activity, they unite and become one organ; in a pathological point of view they are also one, so constant is the interchange of morbid stimuli between the different portions of the generative organs. Thus, during menstruation and the orgasm of sexual intercourse, the Fallopian tubes obey an elective impulse, in virtue of which the fimbriated extremities embrace that particular part of the ovaries whence

an ovule is to escape, so as to receive it, and the fluids by which it is accompanied a fact which has been occasionally noticed in women dying during menstruation. This attraction is the more extraordinary, because at that time the Fallopian tubes are full of mucus, which would seem to forbid the adhesion of the fimbria to the distended ovary; and still this attraction is strong enough to resist the sudden passage of the bladder and intestines, from a state of repletion to that of vacuity. To render this easier, one of the fimbriæ is generally longer than the others, and is attached to the ovary so as to act on the Fallopian funnel in its vicinity. That the fimbriated extremity of the Fallopian tube embraces the ovary during coitus, and when the animal is in heat, has been stated by numerous authors, and positively by Cruickshank, in the following words :-"The Fallopian tubes, independent of their black colour, were twisted like writhing worms, the peristaltic motion still remaining very vivid. The fimbriae were also black, and embraced the ovaria-like fingers laying hold of an object-so closely and so firmly, as to require some force, and even slight laceration, to disengage them."Philosophical Transactions, 1797. De Graaf observed similar phenomena in a woman who had been killed by her husband, on his detecting her in an adulterous act. The periodical congestion of the ovaries was strikingly exhibited in the patients observed by Verdier, and by Dr. Oldham. may therefore admit, that if by any cause this state of congestion were carried to a greater degree than ordinary, or protracted beyond the usual time, inflammation might attack the organ itself; and I find that in many published cases, ovaritis supervened instead of the menstrual discharge, or in the midst of it. The fact of the physiological irritation of the ovary being susceptible of passing into true inflammation is confirmed by the phenomena of ovulation, as they may be studied in the lower animals, and may be accidentally met with in woman.

I

With regard to ovaritis originating in ovulation, few will deny the possibility of this occurrence, if they have ever held in their hands the ovary of a woman in whom the process of ovulation was actively progressing at the time of death; for they will remember the projecting follicle, the diameter of which in

creased from three lines to from five or eight, a soft and fluctuating projection with a central point of brickdust hue, surrounded by its rich plexus of vessels, and where the follicle would soon have burst. Those who have carefully studied this wonderful process will be ready to admit, that from being a strictly physiological process, it may sometimes become pathological, and that ovulation may, like dentition in children, be associated with inflammation. My views on this point have been for some years before the profession, so I prefer to support them by a quotation from Dr. A. Farre's admirable article in the Cyclopædia of Anatomy and Physiology :-" How closely the process of ovulation, in its more obvious conditions, is allied to inflammation, has already been shown. A high degree of vascularity of the part, with increased exudation of fluid and consequent enlargement and tension of the entire organ, terminating in spontaneous laceration of its coats by a process very similar to ulceration, and often preceded and accompanied by a more or less considerable escape of blood: these, together, form a combination or series of processes closely allied in their nature to inflammation, and frequently evidenced by signs usually regarded as characteristic of inflammatory action."

Dr. Ritchie, speaking of healthily performed menstruation, describes the ovarian cells as "passing from the centre of the glands, and perforating the peritoneal coat, in the way of a most gradual and progressive intestinal absorption. The thinning process in the outer covering of the ovaries is so slow, that it is often inappreciable by the naked eye, at a time when, by boiling and by other expedients, the actually-begun absorption of the peritoneal coat may be easily demonstrated. The solution, in its continuity, generally corresponds in extent with the size of the subjacent vesicle; but in the vesicle itself, the opening is never more than barely sufficient to give exit to the ovulum. Ovulation coinciding with menstruation in women who have died from disease has been described as a much more active process. In general, the blood exuded from the surface of the vesicle forms a clot which distends it, but Pouchet has sometimes found the capillaries ruptured in the vicinity of the vesicle; and he adds-p. 137—“ two or three times I have found amidst the fimbria the whole

blood clot which had escaped from the very extensively lacerated vesicle." Raciborski remarks, that as in woman the ovarian vesicles never have a diameter less than fifteen or ten millimetres, and contain a blood-clot about the size of a small cherry, it is not impossible that the amount of blood liberated from the ruptured capillaries of the ovaries may be, under certain circumstances, greater than the peritoneum can bear with impunity, and it will be shown hereafter that some sanguineous pelvic cysts have this origin. The phenomena of ovulation in sows, rabbits, cows, &c., are thus described by Pouchet-p. 134-" Where the vesicle will soon rupture, there appear signs of intense inflammation, and the peritoneum and subjacent cellular tissue become very red and vascular." And-p. 136-"This intense inflammation has so diminished the coherence of that portion of the ovary which surrounds the vesicle, that it breaks down under the slightest traction, and when the vesicles have attained their full development, their culminating point seems to be formed by a mere pulp. Sometimes the gentlest traction applied to a vesicle which was but slightly ruptured, will cause it to burst, and to expel the blood-clot which it contained." the midst of these widely-torn surfaces there sometimes appears a black patch, which has all the appearance of gangrene." The reader will find depicted-Fig. 1, Plate 8, of Pouchet's Atlas-these extensive ruptures, which he has not unfrequently found in the sow, " and which," says he, "coincide with the more intense inflammatory action of the ovary."

If all this is healthy ovulation, I can only say that it is uncommonly like inflammation; or if, as Dr. Ritchie affirms, this is unhealthy ovulation, I agree with him, and give it the name of inflammation. It is evident that, in many cases, the mature follicle becomes surrounded by a mass of hyperhæmic tissues, and the stroma round the cell becomes turgid, softened, and ruptured. This rent surface, doubtless, heals without secretion of pus, in the same way that the vast surface to which the placenta is attached generally heals without any purulent secretion. In both parturient surfaces,

vascular action is worked up to an inflammatory point, all looks inflammatory, but it is not so unless some pathological stimulus intervene. The stroma round the cell becomes

turgid, softened, and almost inflamed, like the gum over the child's tooth, therefore, it cannot excite wonder that, at times, the ovary should then really become inflamed. One might as well wonder that the gums often become inflamed in dentition, since that also is a physiological act. "If an advancing tooth," says Dr. Meigs," may excite such maladies as are attributed to the dentition in children, what must be the extent and power of complication of the ovary in the monthly act of eliminating the ovulum? And," he adds, “I should think we have greater reason to be surprised at the rarity than at the frequency of ovarian diseases, when we know that this process is for so many years performed every month. In admitting that menstruation may coincide with ovarian inflammation, I am not single in my opinion, for Gendrin states, "that the menstrual nisus may rise to an inflammatory type, causing the ovarian pains so common in women, and the ovarian phlegmons so frequently met with in women during menstruation ;" and again, "the rupture of the ovarian vesicle is necessarily followed by inflammation; and its accidental exaggeration is nothing more than ovaritis, which so frequently occurs at menstrual periods."

Dr. Jenner, who was the first to unravel the intricacies of the continued fever occurring in London, has several times seen acute ovaritis originate suddenly in the midst of menstruation. In a late instance, during this period, pain suddenly occurred in the left side; and it was so acute that the patient was literally doubled up. By a vaginal examination, Dr. Jenner detected an ovarian swelling. The patient died a few days after; but unfortunately no post-mortem examination was made.

The position which I brought prominently forward in 1850 has been supported by Aran, Charles Bernard, Négrier, and others. In reporting to the Société de Chirurgie on C. Bernard's Memoir on Ovaritis, Moutard-Martin admits "the intimate connexion between menstrual derangement and ovaritis." Scanzoni, adopting my views, observes that "the maturation of a superficial ovule is simple; but when deeply buried in the ovary, the whole of it may become intensely hyperherniated. It becomes soft, fragile, and of a deep red colour; ruptured vessels and extravasated blood may be

X