When the ovaries must be removed for diseases like cystic degeneration or abscess, the surgeon leaves, if possible, part of an ovary, or he engrafts part of an ovary in the abdominal wound, under the skin, or elsewhere. This grafting is beneficial in many cases, but it has little or no effect in many others. The graft is absorbed and it disappears in a year or two, but before it is absorbed it makes the onset of the surgical menopause gradual and thus prevents much suffering. In thirty-two cases reported by Chalfant[184] the graft gave evidence of functioning in five of seventeen women from whom the uterus and ovaries had been removed; in others it acted for months and then failed; in others it lessened the unfavorable symptoms; in others it had no effect at all. Stocker[185] reported two successful implantations of ovarian grafts and one testicular graft.
Giles[186] says that in his series of 157 cases of double oöphorectomy severe mental depression occurred in various groups in from 10 to 33 per cent., and two women became insane. Sex instinct was abolished in 16 per cent. Dickinson[187] found, in 200 cases where one or both ovaries had been removed, that not more than 20 per cent. fell into the surgical menopause even when the uterus had been taken out; but Giles, in 50 removals of one ovary, found irregularity, diminution, or cessation of the menses in 16 per cent. Carmichael, Valtorta, and McIlroy[188] discovered in animals a compensatory hypertrophy of the remaining ovary after one ovary had been removed. The internal function and nutrition seem to depend upon the ovarian secretion, as atrophy occurs after bilateral oöphorectomy. In all operations upon or near the ovaries there is likelihood of interference with the blood supply of the ovary, either by including ovarian arteries in the ligatures, or by tension of these vessels, which occludes them, or by malposition and prolapse of the ovary, which kinks them: these accidents result in degeneration or retention cysts. In most cases of pelvic peritonitis the uterus is retrodisplaced, and this position prevents cure until it is corrected.
When there is pus in the ovary, resection, in the opinion of gynecologists at present, is not an advisable operation; the ovary should be removed. Watkins,[189] however, says he resects small ovarian abscesses in young women with good results. In resection the blood supply is, as has been said, usually disturbed, and the cause for the operation is, as a rule, the gonococcus, and both these circumstances make the prognosis bad. The stitches necessarily used in resection operations are an additional source of irritation. Turetta[190] speaks in favor of resection in certain cases. A single retention cyst may be resected, especially when pedunculated. Boldt[191] had only one bad result in forty-five resections where a part of the ovary was saved. If the blood supply after the resection is evidently to be poor, resection is useless. Skill in surgical technic has much to do with success in all these cases. When the uterus is removed because of tumors, even near the time of the menopause, if one or both ovaries can be left in, this should be done. In such conservative operations Dickinson found 80 per cent. of the patients free from nervous disturbance at the time of the menopause.
Polak[192] describes an operation for the preservation of the menstrual function in double suppurative disease of the tubes and chronic metritis. He maintains that even if only one tube is infected, both should be removed because this apparently sound second tube will later, almost as a rule, show infection—probably by extension from the fundus of the uterus inside. Ordinarily inflammation of the tubes happens to be bilateral. Owing to the persistence of the gonococcus in the uterine muscle, surgeons are inclined to the removal of the whole uterus and both tubes. After such an operation menstruation ceases, and in the removal of the uterus the blood supply to the ovary is interfered with so that the ovaries degenerate. The consequent artificial menopause has a decidedly injurious effect on the woman's general physical and mental health. The parts of the uterus permanently infected by chronic gonorrhea are the cervical region, the fundus and the partes interstitiales of the Fallopian tubes. Polak advises that in cases where surgeons usually remove the tubes and the whole uterus they should instead cure the cervical infection by the cautery and take out the tubes, but in place of the removal of the whole uterus they should cut out a wedge including the fundus and the partes interstitiales of the tubes. This leaves the body of the uterus and does not injure the circulation to the ovaries. In the last seventeen cases thus operated upon by him he had success.
When it is necessary to remove both ovaries and tubes an opinion very common now is that it is better to take out the uterus also, because in such cases the uterus and vagina atrophy and this condition later causes trouble. Giles came upon such trouble in 11 per cent. of sixty-two cases. As the uterus is useless after the removal of the ovaries and tubes, there is no reason why it should not be removed. The danger of atrophy is sufficient reason for the mutilation. In operations for pelvic peritonitis it is well to remove also the appendix, because it is nearly always diseased, or it will give trouble from adhesions later and cause a secondary operation. It has no function we know of at present.
In conservative surgery of the uterus and adnexa for pelvic inflammatory diseases, the results attained by four skilled surgeons are: Giles cured 90 per cent. of 132 cases; Polak cured 35 per cent. of 300 cases; Robins cured 100 per cent. of 20 cases; Norris cured 73 per cent. of 191 cases. Polak's patients became pregnant after operation much oftener than those of the other operators. Seventeen per cent. of his patients, from whom he removed one ovary and resected the other, became pregnant. Giles found that of his married patients under fifty years of age at the time of the operation 25 per cent. became pregnant and went to term. They bore twenty-five children. Five of these also miscarried. In sixty-eight of Morris's cases seventeen were delivered of living children after the operation; three had two children each, one had three children, and there were seven miscarriages. In one of his cases where he removed one ovary and both tubes, the woman bore a healthy full-term child two years after the operation. Dudley[193] found that about 10 per cent. of 2168 cases of resection became pregnant after operation. Ectopic gestation is likely to occur in a few cases after conservative operations. Giles had seven such cases in his series of 132 operations, Polak one, and Norris two.
When it is necessary to remove the uterus, the choice between supravaginal hysterectomy, where the cervix is left in after the destruction of its mucosa, and panhysterectomy, where the cervix and the body of the uterus are removed, offers no moral problem except the necessity of deciding upon what will be best for the woman. Rupture of a pus tube is a very dangerous accident—all the patients suffering from such a rupture die if not operated upon, and fifty per cent. die even after operation. A physician may do this damage by ignorant or careless examination, and he may be morally responsible for the death. The accident happens not unfrequently from marital congress, and if the husband has been warned by a physician but does not heed this warning, he is guilty of murder if the woman dies after rupture of the pus tube.
Pregnant women are more liable to infection by the gonococcus than non-gravid women, because of the increased blood supply to the generative organs in gestation, and the softening of these organs. For the same reason, latent gonorrhea is likely to become active and to spread during pregnancy. A like activity and extension of latent gonorrhea often occurs during menstruation. Women with gonorrhea are commonly sterile—this is the chief reason why prostitutes are usually sterile. In married women gonorrhea may cause dyspareunia; it may bring on abortion through endometritis; it may shut the tubes and prevent conception; it may destroy the ovaries.
The disease is extremely frequent during pregnancy. Gurd[194] isolated the gonococcus in 52 of 113 pregnant women who came to his dispensary service because of pelvic pain. Leopold, Stephenson, Fruhinholtz, and many others estimated that about 20 per cent. of all pregnant women have gonorrhea, but more recent observers think that from 5 to 10 per cent. is nearer the truth.
When a pregnant woman has gonorrhea great care must be taken in treatment to prevent abortion. Powerful antiseptics in the cervix, or dilatation of the cervix, are not permissible, and operative interference is to be delayed as long as possible—in each instance to avoid abortion. The vaginal douche as a routine treatment is not used now by obstetricians in these cases. When the gonorrhea is in the uterus douches of hot bichloride solution, 1 to 10,000, are used twice daily during the last few weeks of gestation, with the intention of saving the infant's eyes from infection during delivery. After delivery the cavity of the uterus should not be entered with instruments lest infection be carried in, unless absolute necessity requires this instrumental procedure. Post-partum gonorrheal sepsis is differentiated from other septic conditions chiefly by the history of gonorrhea in the husband, by bacteriological examinations, and by the technical differentiation of symptoms.