CONSERVATION OF THE OVARY,*

BY WILLIAM A. HUMPHREY, M.D., Toledo, Ohio.

Conservation is the spirit of the times. As applied to the ovary we mean such measures in the practice of Gynaecological Surgery as will preserve as much of the gland as is possible, with the hope of retaining its function, and while every surgeon present can, no doubt, testify from clinical experience to the benefits to be derived from such practice, yet a discussion at this time of the extent to which it may be carried with the hope of good results, may not be untimely.

From its anatomical makeup the ovary is predestined to have its share of trouble. From its location in the human anatomy it is often the victim of its bad neighbor when it was only an innocent bystander. In addition to its glandular structure its investments are of such a nature that its vulnerability is much greater than might be imagined by those who have not considered carefully its origin and makeup. For instance, the ovary has for its outer coating a membrane which is derived from the posterior layer of the broad ligament which differs essentially from the peritoneum in being covered by columnar epithelium; thus the outer membrane of the ovary is mucous and not serous. Its arteries are derived from the abdominal aorta and anastomose with the uterine; its veins form the pampaniform plexus and empty into the ovarian vein which in turn empties into the renal vein on the left side and into the inferior vena cava on the right, similar to the spermatic veins in the male. The lymphatics anastomose with the trunks from the uterus and Fallopian tubes and terminate in the lumbar glands. In health the ovary is the only pelvic organ that is acutely sensitive, which, like that of the testicle, is especially characteristic.

From the nature of its outer mucous covering it is easy to understand why it should so readily accept any infection conveyed to it through the Fallopian tubes from the mucous surface of the uterus, whose membrane possesses a similar formation. For similar reasons infections are carried through the veins and lymphatics owing to the anastomosis with those of the uterus. For clinical reasons we should remark that the ovary can be palpated by bi-manual examination, and by way of contrast we might add that the Fallopian tubes cannot be palpated in health.

Attempts at conservative surgery of the ovary have their advantages and disadvantages. The advantages are mainly in retaining its function and the prevention of the psychic and physical disturbance by the artificial production of the menopause. Kelly says, "There is a growing conviction that the ovary belongs to the same group of organs as the thyroid, thymus and pineal glands and that in addition to the function of ovulation, it secretes a sub+ Read before the Ohio Homoeopathic Medical Society, May, 1911.

stance which is absorbed and consumed in the animal economy, and which is necessary to its physiological balance."

Other authorities are of the same opinion, and the trend of opinion is toward the corpus luteum as the particular portion of the ovary possessing this function. Whether or not such a function exists has not been demonstrated, neither can we determine whether the mental and physical phenomena produced by the menopause, artificial or natural, are due to the cessation of this hidden function or whether it is due to the mental effect alone. The serious mental disturbance produced by induced menopause, especially in the young, is in many cases very grave, and this alone has induced operators to leave ovarian tissue whenever possible, and many times to the further hazard of the patient.

The disadvantages of conservatism are: first, the unlikelihood of restoring the function; second, the return of the disease to the part left; third, the occurrence of the disease on the opposite side; fourth, the failure to cure; fifth, the risk of ectopic gestation; sixth, the danger of infection following resection; seventh, the unnecessary risk of life from a secondary operation.

Ovulation is not usually interrupted in diseased ovaries so long as any functionating tissue is left. Diseased ovaries are not usually so without a badly diseased tube, and consequently the ovary left after the removal of the tube can only perform such office as may assist the mental equilibrium. Personally I believe such function does exist and can be shown by analogy in animals. The possibility of the return of the disease to the remaining tissue must be admitted. Yet we are warranted in the risk, with the patient's consent.

Extension to the opposite side is not a great risk if the endometrium is attended to, or in case of doubt the tube on the opposite side may be removed and the ovary allowed to remain.

Failure to effect a symptomatic cure cannot be charged to conservatism, for post-operative pain is common after complete removal of the tubes and ovaries and is due to adhesions which are common in abdominal procedure.

Kelley says, "No authoritative case of extra-uterine pregnancy after conservative operation upon the tubes and the ovaries has been recorded."

Danger of infection in the presence of pus is extremely well. taken, but in non-purulent cases there is no such risk.

The risk of secondary operation is remote in selected cases, and the fact remains that the patient should have the right to choose in all cases.

Conservative work has produced some remarkable results of pregnancy following operations upon the appendages. These operations have shown that conception has taken place after conservative procedure for almost all known pathological conditions of the appendages, viz., adherent tubes, ovaries and uteri have been restored to their normal functions. Pregnancy has existed.

after puncturing cysts of the Graafian vesicles and the corpus luteum; after resecting the ovary and leaving a small portion; and after excision of a hematoma. Kelly has reported the existence of pregnancy after leaving one tube and the opposite ovary. Atrophy does not necessarily interfere with ovulation and such an organ should not be sacrificed if the opposite side is removed, as pregnancy has been known to follow a conservative operation which left only a single atrophic ovary. (Ashton.)

The removal of the ovaries and thereby inducing early menopause is sometimes justified in cases in which there has existed severe endometritis with discharge for a long time, with fair promise of relieving the discharge. In such cases conservatism should demand careful removal of the tubes also, so that there shall be no traces of infection outside the uterus. Many of these cases will be cured after the atrophy has taken place, while others will not be improved. Opinions upon such cases should be most guarded.

General contra-indications for conservative surgery upon the ovary or tubes should be well understood lest we place at the door of conservatism failures which should never have been tabulated in that column.

The chief contra-indications to conservative surgery of the ovary are: the presence of pus, the age of the patient, and malignant disease.

When pus is present in the gland no attempt should be made to save any of the organs. The risk of infection as well as the probable failure to restore function, the few successful cases reported, all furnish sufficient argument to cause the abandonment of conservative means for the radical under such conditions.

Age is an important factor. In the young the functions. should be preserved when possible, both for the mental and the physical effect. In those nearing the menopause in which, as a matter of course, the child-bearing age is nearing its close, the matter of preservation of function is not of the same importance, while the nervous phenomena are not so much to be dreaded as in the years of earlier menstrual life.

In the presence of malignant disease there is no place for conservatism except at the patient's own risk. Operative measures should always be thorough and complete in these cases.

After all, the limits of conservatism upon the ovary are very narrow adhesions may be removed and, granting a patulous tube, with the released ovary in proper position, we may reasonably expect resumption of function.

Cysts of the Graafian follicles and the corpus luteum are seldom. so numerous in a given ovary as to warrant its removal. If small they may be punctured; if they are large they may be incised and their walls removed, while the incision should be closed.

Hematoma, if small, may be removed without sacrificing the

ovary, but if the hemorrhage should be profuse, involving the whole organ, it should be sacrificed.

In glandular dermoid cysts, where only one ovary is involved, the whole organ should be removed, while if both sides are involved, an effort to save some healthy ovarian tissue is justifiable. In benign tumors the same general rules hold good.

Prolapsus of the ovary is not sufficient grounds alone for its removal. Unless grossly diseased it should be anchored to the pelvis by shortening the infundibulo-pelvic ligament. This is a simple matter and done readily by passing a small ligature twice through the ligament at the outer edge of the ovary and carrying it through the peritoneum and underlying structures above the pelvic brim in front of the iliac artery. This will fix it outside of the pelvis.

In simple atrophy many times the ovaries are made so by adhesions. It is often wise to save the one in the best condition.

The procedure in each individual case is a matter for the careful consideration of each individual operator. In this day of rush and hurry with so many near-surgeons it is an easy matter for mutilation to be given first place over that of legitimate, careful, painstaking work. We have seen cases in which the tubes were grossly diseased from pus surrounded by dense adhesions, in which the ovaries were firmly bound, and yet producing fair promise of functionating under ordinary circumstances. Careful removal of these tubes with the release of the ovaries from the adhesions and, where possible to save only one, the patient would make a good recovery, the menstrual function would be maintained and premature menopause avoided. With even a part of one ovary left these cases avoid all the mental and physical symptoms of an enforced menopause and go on through life as if nothing had happened. Case after case might be recited with little profit perhaps, yet we should not forget that our duty to our patient, first of all, is to preserve all the tissue and every function possible while attempting to relieve her of pathological conditions. We have said nothing about internal medication in the management of these cases. Just how much can be done with internal medication toward relieving a real pathological condition in an ovary will always remain a disputed question. All of us, no doubt, have confidence in carefully selected remedies relieving certain conditions of the ovaries, but just how far we can go will always remain a disputed question because of the uncertainty of medical diagnosis in these organs. We should, however, be satisfied with a symptomatic cure and if the patient remains well there is no excuse whatever for surgical interference. The question, however, of careful diagnosis, and the recognition of pathological changes is one of the utmost importance to us in our efforts to handle these cases, because our own reputation and the success of the case depend a great deal upon our ability to determine when they cease to be medical and become surgical.

CLINICAL DEPARTMENT.

Conducted by A. H. RING, M.D.

Case VI.-Diagnosis: Cortico-Spinal Lesion on the Right Side.

This case offers food for much thought; certain things are clear at the outset. Its limitation to the left side with spastic knee jerk, toe drop and typical ankle clonus at once excludes the neurosis and places it in the organic group. The spasm always beginning in the left fingers and then extending to the left leg, but sometimes instead spreading to the neck and left face, especially the jaw, characterizes the epilepsy as Jacksonian, and places the lesion about the middle of the right pre-central gyrus. The fact that it is accompanied by epileptiform seizures makes it probable that the process is at the cortex and not sub-cortical. The question then arises: what sort if a lesion is it?

We must consider embolus, hemorrhage, pachymeningitis interna, and tumors, especially gumma. This last, however, is very remote and may be excluded, since there is no specific history or suggestion of it in the case, and no headache, vomiting or persistent vertigo.

If embolism or sub-cortical hemorrhage is to blame, then it occurred when she had the acute attack at twenty-two years of age and it left a small walled-off cyst which remained harmless until the slight blow on the head a year and a half ago, which trauma caused it to light up and spread somewhat. This theory, however, does not explain the hysterical attacks as a child which began with the sunstroke when about eight years of age. It is consistent with the facts that this sunstroke was the excitant of a pachymeningitis with the formation of a slight false, friable, sub-durable membrane on the right side, which became well organized and caused little trouble beyond occasional numb spells until the summer of her 22nd year, when a small vessel ruptured, the hemorrhage flattening downward and exciting by pressure the face centers. This in turn organized and the membrane again became innocuous until she became run down by trouble and received the blow which ruptured another vessel, this time further up and pressing upon the leg centers. This last clot was of larger size and had exerted persistent pressure upon the cortex with resultant degeneration. of the left pyramidal tract. The latter hypothesis seems to most completely fit the fact.

Case VII. For diagnosis:

A small, fair woman aged thirty years, married six years, has one child. F. H. unimportant. She has always had average health; does her own work. Has always had a clear, clean, somewhat pale skin. A week ago she noticed a pink eruption on the chest which soon spread to the hips, abdomen, back and thighs, especially the inner surface. The arms and face have not been attacked, but there are now a few spots appearing on the flexor surface of the forearm. The spots were at first a faint pinkish