If the abdominal operation be performed, the incision should be made between the navel and the pubes in the median line, and not over each ovary, as advised by some authors. One great caution must, however, be observed, and that is not to wound the intestines. In ovariotomy the cyst is in front of the intestines, and there is very little danger of injuring the latter. But in cases of öophorectomy, no tumor being present, the bowels lie in contact with the wall of the abdomen, and are very likely to be wounded by the knife when the peritoneum is incised. The incision should be long enough to admit two fingers. These, being passed behind the womb, are conducted to the ovary by gliding along the oviduct as a guide. Each ovary, together with its oviduct, is in turn brought up to the opening. It is then seized by a fenestrated polypus-forceps and its stalk transfixed, tied on either side with fine silk, cut off, and dropped back into the abdominal cavity. Should the stalk be so short that ovarian tissue is left behind in the button of the stump, it should be destroyed by Paquelin's cautery, for it is astonishing how small an amount of this tissue will keep up not only menstruation, but even menorrhagia. On the other hand, it will not answer merely to ligate the pedicles without removing the ovaries. This has been tried, and not only did menstruation continue, but in one instance pregnancy took place.7
7 Murphy, British Medical Journal, April 18, 1885, p. 787.
The dressing is precisely the same as in ovariotomy, and, like it, the operation should be performed with every detail of antiseptic surgery.
In the vaginal operation the vagina first should be thoroughly cleansed with a solution of carbolic acid, and the patient placed on her back and not on her side. I am convinced from experience that the usual left-lateral position is a dangerous one, for as soon as the peritoneum is opened the air rushes out and in during every inspiration and expiration—an untoward circumstance which cannot happen in the dorsal position. A duckbill speculum is introduced, and the perineum pulled downward. The cervix uteri is transfixed by a strong thread, by which the womb is drawn downward and forward. The post-cervical mucous membrane is next caught up by a uterine tenaculum and snipped open for about an inch. The index finger of the left hand is then passed in, and each ovary brought down to the incision by the finger-tip hooked into the sling made by the oviduct. The ovary is seized by a fenestrated forceps and brought into the vagina, where its stalk is transfixed by passing a needle armed with a double thread between the ovarian ligament and the oviduct, and each half is securely tied. The ovary and the fimbriated end of the oviduct are then removed, the ligatures cut off at the knot, and the stumps returned into the pelvic cavity. To close the vaginal opening one or two stitches will be needed, and finally the wound is covered with iodoform and the vagina gently packed with pads of carbolated or salicylated cotton.
It is a fact worthy of note that during the week following the ablation of the uterine appendages a sanguineous discharge from the womb usually takes place. This is in no wise a menstruation, but a metrostaxis set up by the irritation of the ovarian nerves, caused by the means adopted to secure the pedicles. Candor, however, compels me to say that for some inexplicable reason the removal of the uterine appendages—viz. ovaries and oviducts—does not always bring about the change of life. These cases are exceptional, and they are supposed to be due to either the presence of a third ovary or to some small portion of ovarian stroma left behind.
This operation in no wise unsexes a woman or changes her appearance or character. It simply brings on the change of life with its attendant phenomena. Her instincts and affections remain the same, her sexual organs continue excitable, her breasts do not wither up, and she is no less a mother or a wife.8
8 Lessons in Gynæcology, by Wm. Goodell, M.D., chap. xxvi.
Extra-Ovarian Cysts.
There is a class of tumors which, while not ovarian, lie so near to the ovary as often to involve it, and usually need precisely the same treatment as cysts of that organ. In their extirpation the ovary is almost always also involved. This close anatomical relationship makes it needful to describe them in conjunction with ovarian tumors. They comprise Cysts of the Parovarium, Cysts of the Oviducts, or Fallopian Dropsy, and Cysts of the Terminal Vesicle of the Oviduct, often called the Hydatid or Vesicle of Morgagni.
Cysts of the Parovarium.