In cases where the gonorrheic or other bacterial infection has been chronic in the uterine adnexa, palliative treatment will in a certain percentage of cases make surgical intervention unnecessary, and when such treatment does not avail we must decide between the total removal of organs and the partial removal. Partial removal is called conservative surgery, and the term conservative is used as a synonym of preservative. Prochownick[176] reported 420 cases where pus in the tubes or ovaries was let out extraperitoneally, and no organs were removed. Of these cases, one hundred and sixty, or 38 per cent., were permanently cured. Fourteen of the one hundred and sixty who had received only one treatment subsequently gave birth to children, and three aborted. After a second treatment twenty-seven remained well and three became pregnant, of whom one aborted. Olshausen,[177] a great authority in gynecology, used the palliative treatment, and he commonly waited for nine months after the infection and until the temperature was normal. Goth[178] reported excellent results in seven hundred cases of pelvic disease treated by the palliative method. The chief objections to this method are the time required to get the result, and the difficulty of controlling the patients and their chronically diseased husbands, who reinfect them despite the medical prohibition of marital intercourse.
In cases of chronic pelvic peritonitis the question comes up frequently whether the womb and both tubes and ovaries should be removed wholly or in part. The text-books decide the question without any heed whatever to the notion of the morality of mutilation as such. They take into account the age of the patient, whether she has children or is desirous of maternity, whether or not she supports herself by manual labor, her temperament and character, and the results attained by men who have tried various methods of operating.
The conservative surgery of the uterus and its adnexa in gonococcal pelvic peritonitis was for many years looked upon with disfavor by surgeons. These conservative operations often failed or later required secondary intervention. Preliminary palliative treatment as now used greatly lessened the number of failures. Operations in peritonic conditions are dangerous because they may let loose encysted bacteria and start up a general septic peritonitis, which may be fatal. By delay and palliative treatment the virulence of the bacteria subsides, except where the woman is reinfected by her husband. In any case the blood-count should have been normal for at least a month and a half before any surgical interference is attempted. Olshausen waited nine months to let nature disinfect the pus.
The removal of a part of a tube is called salpingotomy; the taking out of the whole tube is salpingectomy; the opening up of a shut tube is salpingostomy. The presence of pus in a tube is absolute indication for removal according to the gynecologists at present. Howard Kelly and others have succeeded at times in such cases with conservative surgery, yet such treatment is now deemed obsolete—the dangers and failures seem to overbalance the little good effected. The end of conservative surgery is to try to restore function without pain, to preserve menstruation and ovulation, to put the organs in a condition to make pregnancy possible, and to preserve the internal secretion of the ovaries. The ovaries, so far as the woman's health is concerned, are the most important of her generative organs. If a woman is at the end of her child-bearing age there is no reason to preserve the tubes when they are affected, and conservation is likely to fail; but the ovaries should always be preserved, wholly or in part, when possible.
If one tube is infected from the uterus many gynecologists are inclined to remove both tubes. When a single tube is affected the cause is seldom the gonococcus, but some other bacteria which are not persistent. When both tubes are affected the cause is commonly the gonococcus, and attempts at preservation then fail, as a rule. Norris, who is a reliable authority, holds that "the only cases in which a salpingostomy is justifiable is on old, non-active hydrosalpinges, and in those cases of tubal occlusion or phimosis resulting from extratubal inflammation, such as sometimes result from appendicitis or ectopic pregnancies."[179] When a tube is shut, if it can be opened the opening tends to close again. A few cases of subsequent pregnancy have occurred after salpingostomy, but such a result is exceptional, because the origin is usually the gonococcus, which destroys tissue and is very persistent.
The ovary corresponds to the testicle, and the Fallopian tube to the vas deferens. Removal of the ovaries, or removal or closure of the Fallopian tubes, renders the woman sterile, but removal of the ovaries has other profound effects beside sterility. Loss of the ovaries brings on suppression of ovulation, menstruation, pregnancy, and ovarian internal secretion, various neuroses, and a tendency to insanity in certain cases.
The testicles and prostate gland produce an internal secretion containing spermin, and the ovaries a similar nitrogenous base called ovarin, which acts like spermin. The suprarenal glands secrete epinephrin; the thyroid gland and the pituitary body also make internal secretions, and these secretions sustain the tone of the blood-vessels and effect immunity against those toxins that arise from metabolic waste substances while these are in the body before elimination. If there is a hypersecretion from one or more of these glands, the excess causes congestion of the cerebrum and cerebellum and of the nerve centres there, and one effect may then be a sexual erethism that leads to masturbation and similar deordination.
Castration in the male or ovariotomy in the female stops all production of spermin and ovarin. In man the prostate gland also ceases its function after castration, and vasectomy lessens the production of spermin. In castration or spaying, again, when we remove the power of producing spermin or ovarin, that function of the testes and ovaries whereby the body is immunized against poisoning by its own effete material is also inhibited, and evil effects arise from this waste material. These toxins act just as would an excess of spermin or ovarin—they congest the cranial nerve centres, excite fever, neuroses, or temporary sexual erethism. This excitement may gradually subside as equilibrium is restored and neutralization effected, through a compensatory overproduction of the internal secretions by the other glands remaining in the body. Cimoroni[180] found after ovariotomy an increase in size of the pituitary body with dilatation of the blood-vessels. Goldstein[181] reported a case of gigantism from overactivity of the pituitary gland after castration. Acromegaly in cases where there was no castration has been accompanied by atrophy of testicles and ovaries. Cecca[182] found like effects in the thyroid, and several have observed these effects in the adrenals. All these results have also been produced experimentally on animals.
Women at the menopause frequently are observed who have become neurasthenic from the irritation of waste material intoxication which is not neutralized because the ovaries are ceasing to function. Ovariotomy in younger women produces this menopause artificially and suddenly; and women from whom both ovaries have been removed, as a rule, become neurotic invalids with a tendency to insanity if they are unstable in character or have a bad inheritance. If the whole thyroid gland is removed, death results from intoxication. Extreme obesity is an effect of undersecretion by the glands and a consequent lack of oxidation. Fat children have deficient glands, as a rule, and eunuchs grow fat as capons do. Removal of the ovaries before puberty arrests or prevents the development of the uterus; removal after puberty stops menstruation, the breasts atrophy, and there is an arrest of general physical growth.
Gordon[183] reported on 112 cases of oöphorectomy. Of these thirty-four had had before operation various symptoms of neurasthenia, hysteria, or psychasthenia, and vague abdominal disturbances. Surgeons in each of these thirty-four cases blamed the ovaries for the symptoms; and although these organs were not diseased in any degree, the surgeons removed them. In twenty-five of these cases there was no improvement whatever; in the remaining nine there was improvement for a few weeks, but complete relapse later, and finally their symptoms grew worse. The obsessions became permanent and expanded. Those women in the group who had hysterical paroxysms began to have stronger and more frequent attacks. Several psychasthenics had to be confined in asylums for the insane. Three of the women who had complained merely of vague nervous symptoms, as pain in the abdomen, head, or back, or of constipation or diarrhea, after oöphorectomy grew irritable, highly nervous, quarrelsome, fickle, restless, showed a tendency to travel about, to complain of others; finally there was insomnia, and loss of appetite or voracity. In the remaining seventy-five cases one or both the ovaries were diseased, but both ovaries were completely removed. All these women developed symptoms like those described above, but several grew much worse in their mental condition than the psychasthenics among the first thirty-four women. The generally observed symptoms are: restlessness with a tendency to move from place to place; loss of self-control; dissatisfaction with all persons and things; want of interest in work; indolence; pessimism. Sometimes there are outbursts of anger, with a tendency to attack. The mental conditions do not, as a rule, become clearly developed melancholias or manias, although a few do grow definitely insane. The morbid symptoms, however, persist obstinately. After ten years' observation Gordon found no improvement in some of these psychasthenics.