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J. A. (Joel Asaph) Allen.

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disputed points out of the field. Experience has given something
of definiteness to our views ; still there are two camps. The
disputed points involve methods, rather than questions, of the
justifiability or safety of the operation ; on these points there is
unanimity of sentiment among experienced surgeons. There may
be yet some division of opinion as to what cases should be oper-
ated on, and what cases should be let alone. The operation was
long regarded as one of the most fatal in surgery. The low rate
to which the mortality following the operation has been reduced
where the cases fall into experienced and skilful hands, has given
it an abiding and important place among the life-saving procedures.
In the matter of methods, men are likely to credit those methods
with being best which, by their own tests and in their own
individual and professional experience, have given the best results.
One or more failures with any one particular method of procedure
drives some' men to try others. With their first success they
christen the baby, " My method," " My modification," " My
improvement," or ^< My invention," and the entire profession is
exceedingly glad that a new genius has been born into the profes-
sion — that there is a new light in Israel.

The history of the treatment of the pedicle in ovariotomy has
influenced all of the older ovariotomists to try the same methods
and materials to perfect an intra-peritoneal method in hysterectomy.
The early efforts of Schroeder were quite successful. Some of the
younger operators have impro.ved the statistics by clean extirpa-
tion, but we yet remain in two camps as to the management of the
pedicle.

Operators clinging to the noeud and the extra-peritoneal method
are making the best showing, operating right along with a very
low mortality. It cannot be inferred from the success of the intra-
peritoneal method in ovariotomy that improved or equally success-
ful results will be attainable by the intra-peritoneal method in
supra-vaginal hysterectomy. The results in many large and ripe
experiences establish the fallacy of this idea ; such inference is
in blind disregard of essentially different conditions. Ligatures
cannot be safely used in uterine fibroid, or myomatous tissue.
£ilk, as applied to the pedicle in cystomas, is harmless and safe.



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28 SOCIETY PROCEEDINGS.

I would say here that the earlier errors in diagnosis, mistaking
cystiform degeneration, fibroids, or edematous myomas, for ovarian
cystoma, were common, and the cases were either abandoned or
incomplete operations done with disastrous results. Some of the
most skilful operators did not escape making these errors.

The treatment of the pedicle has been repeatedly and exhaus-
tively discussed. Results have dampened the enthusiasm of the
advocates of the intra-peritoneal method.

It is necessary in the removal of about all fibroids to make a
pedicle. Its manufacture in extra-peritoneal hysterectomy is the
one important feature of the operation. It should be made small.
Suturing securely against hemorrhage is also the important
feature in the intra- peritoneal, and the avoidance of hemorrhage
and the ureters are the important features in the extirpation
method.

Shock is minimized in the extra-peritoneal method, the opera-
tion being shorter, exposure and manipulation less, than in any of
the intra-peritoneal methods.

The methods of turning the pedicle into the vagina is a tedious
operation ; the risks of hemorrhage and of injury to the ureters is
even greater than that of a clean extirpation of the cervix.

The question is often asked, Why leave the cervix or stump
in at all ; it is the most common source of hemorrhage and sepsis
in all the intra-peritoneal methods ? Its removal is the perfected
operation, but the results as yet have not been as good as in the
extra-peritoneal method of treating the stump.

Hemorrhage is incident to the supra-vaginal, as it is to all the
methods. The bleeding varies greatly, and sometimes is absent
altogether. In this procedure the elastic ligature (Kleeberg's) and
the wire ligature minimize the risks of hemorrhage. The chief
danger in tte intra-peritoneal method is bleeding from the pedicle.
Drainage, or the dry treatment, where adhesions have been exten-
sive, is of vital importance in these operations. It is an important
object to get and keep the stump dry. In some cases the dress-
ings need not be changed for a week or more. They should be
changed when they become moist. The advantage should be kept
in mind of sewing the edges of the peritoneum across the stump,
thus preventing retraction when the loop has become somewhat
loose from the shrinkage of tissue. The duration of the operation
is one of the many factors to be considered. There should be that
rapidity consistent with due caution and scrupulous attention to



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PHILADELPHIA COUNTY MBDICAL SOCIETY. 2»

essentials. There is no time for f ussiness. There is the shook of
the anesthetic. Extensive adhesions, bowel and bladder compli-
cations, require painstaking surgery, and tedious and slow the
steps of the procedure, and somewhat lengthy, however deft and
educated the hands engaged. Temperature is an important con-
sideration. Supplying dry heat throughout the operation will
avoid, to a very great extent, the shock due to the chill of the
atmosphere. In the matter of shock, long exposure and long
anesthesia count for much. It should be kept in mind, however,
that to deal with an abdominal wound carelessly or too hurriedly
is bad surgery. Every step should be timed to the needs of the
case, every motion those of a master- work man, and there should
be summoned into service every resource of our science and
art.

When we come to consider hysterectomy in all its phases, the
condition of the patients when they come into our hands, the dire
extremity that drives them to us, that they come to us with gen-
eral health broken down, often complete physical wrecks, and
familiar as we are with resultant issu<;S — we have no difficulty in
appreciating the difficulties we have to encounter. The profes-
sional responsibility is a heavy one. The patient's condition sug-
gests the urgent question : What should be done ?

We appreciate the truth of J. Knowsley Thornton's statements;
we accept them in the main as surgical truths, into the acceptance
and practice of which the profession should be educated. As to
the relative value of two very different surgical procedures for the
cure of fibroid enlargements of the uterus, he says :

I feel that I am confronting one of the most difficult questions In
abdominal surgery armed with imperfect weapons. Medicine has long
and vainly endeavored to deal satisfactorily with this disease, and now
the surgeon^s aid is invoked. I do not deny that many cases have been
relieved by medical treatment, and that some have been cured while
under such treatment I do think, however, that it is an open ques-
tion how many of the cases cured while under treatment were cured by
the treatment, and I believe the majority of such cures have been due
to the coincident interposition of Dame Nature.

A very large number of patients never suiter pain, or even incon-
venience, enough to make them consult either physician or surgeon.
But admitting all this, there undoubtedly remain a large number of
cases urgently demandiag surgical aid. Some patients are brought
face to face with death from hemorrhage, excessive growth of the mor-
bid elements, or constant interference with rest from pain and discom-



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30 SOCIETY PBOCEEDINOS.

fort. Others are grradually but surely reduced in strength, and have
lesions of vital organs as the result of constant pressure and displace-
ment. When surgical treatment is spoken of, we are told that we have
no right to interfere with fibroids as we do with ovarian tumors,
because the latter surely kill if left alone, and the former do not. I am
certain that this argument is only partly true, and everyone who sees
a large number of cases will bear me out in the statement that numbers
of women die every year from the direct and indirect effects of fibroid
enlargements of the uterus.

I would ask. How much of the general surgery of the day which is
dangerous to life would continue if surgeons ceased to perform opera-
tions of expediency, that is, to operate for deformities and diseases
which do not endanger life in themselves, though they deprive their
victims of all the pleasures of life ? I affirm, then, that there are many
cases of fibroid enlargement of the uterus which endangers the lives
of their bearers, and that there are many more which make these
poor suffering women so miserable and useless that they are justified
in running the risks of operation, and that the surgeon is justified in
operating. We must remember that these operations are usually under-
taken in extreme cases, and when the patients are worn out with disease
and suffering.

The operation of complete supra- vaginal hysterectomy, with removal
of both ovaries, has become, when properly performed, one of the most
successful of the great operations.

Hegar and Kaltenbach, by their new extra-peritoneal method, have
saved eleven cases out of twelve, and the surgeons at the Samaritan
Hospital have in the last year had equally successful results, also by
the extra-peritoneal method, using Koeberle's wire serre-ncBud in much
the same way that Hegar used the elastic ligature. These operations
of hysterectomy and complete supra-vaginal hysterectomy still remain,
however, very formidable operations. They are terrible mutilations ;
the patients are slow in convalescence. Is there, then, no operation of
less danger, of quicker convalescence, and of better and more perfect
results which we, as surgeons, can recommend to our patients.

Thanks to American surgery, the brilliant conception of Blundell,
in 1823, was made a recognized surgical procedure by Batty in 1874,
and from the labors of Hegar, Trenholm, Tait, Savage, and others, I
am able to present to you a perfected operation, which will render this
formidable hysterectomy still less often necessary in the future than it
has been in the past.

The complete removal of the uterine appendages, when efficiently
performed, cures fibroids of the uterus with rapidity and certainty.
And I will ask you to remember that this operation is not such a serious
mutilation, and does not leave behind it any mark except a small linear
scar on the perfectly closed abdominal parietes. The removal of the



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PHILADELPHIA COUNTY MEDICAL SOCIETY. 31

Uterine appendages is attended with infinitely less danger to life than
are the yarious operations for the removal of uterine fibroids.

Are we, then, justified in subjecting our patients to the formidable
operation of supra- vaginal hysterectomy when we can cure them by
removal of the uterine appendages ?

It should be accepted as a settled fact that we are never justified
in doing a hysterectomy when the appendages can be removed
early in the growth of the tumor.

DISCUSSION.

Dr. Charles P. Noble : It has been a very short time since
we were all firmly imbued with the idea that for fibroid tumors^
practically, we should never operate. They were considered to be
benign tumors, not endangering life, and it was held that by the
use of ergot, muriate of ammonia, etc., the serious symptoms could
be combated. It, however, did not take a long experience to con-
vince me that fibroid tumors are much more serious than our elders
taught, and I am quite certain that it is the experience of every
one that fibroid tumors do bring patients to the brink of the grave,
and even cause death, either by long exhausting hemorrhages, or
by attacks of peritonitis, (although such attacks are usually due to
coincident disease of the tubes,) or by pressure on other organs in
the pelvis, especially the ureters. In addition, when fibroids attain
any size, they may degenerate into fibro-cysts, or be converted into
sarcomata. There is no doubt that not an inconsiderable number
of fibroids become malignant. A consideration of these facts has
determined me that hereafter I shall operate on fibroid tumors
which cause much hemorrhage, or much suffering, or have attained
considerable size.

I agree with Dr. Price, that when the fibroids are small, the
removal of the appendages is a simple, safe, and curative operation.
In all the cases in which I have done this operation, the results
have been all that could have been expected. In every case the
patient recovered, and in every case the fibroids became much
smaller, the hemorrhages ceased, and the patients were sympto-
matically cured. I think that an exception should be made where
there is a single fibroid which can be removed from the uterus, and
the bed from which the fibroid has been removed can be closed by
stitches, thus leaving normal appendages and practically a normal
uterus. I have never done this operation, but I have had several
patients under my care who had been operated on in that way, and
the results were all that could be desired.



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32 SOCIETY PBOCEEDINGS.

With reference to hysterectomy, I believe that the technique
of this operation is undergoing a change ; and while at the pres-
ent time the extra-peritoneal method with the use of the serre-ncBud
may be giving the best results, I have no doubt that in the near
future two other methods of doing hysterectomy will give equally
good results, and they have certain advantages over the serre-nceud,
and will, I think, come to supplant that method. I refer, first, to
the method of tying off the broad ligaments down to the vagina,
separating the bladder in front and amputating the cervix and
stitching the peritoneum over the cervical stump. This operation
has been done most frequently in this city by Dr. Baer, and his
results have been most excellent. I have done the operation. It
is a simple operation, and I believe that it is destined to supplant
the use of the serre-noeud. The second method to which I have
referred is the complete extirpation of the uterus. With the
patient in the Trendelenburg posture it is a simple matter to re-
move the entire uterus, and when the patient is in good condition
it can be done without any marked increase in the length of time
which the operation takes. If it is desired, the ligatures can be
brought out into the vagina. We then have a perfectly clean peri-
toneum with a simple seam extending from one side to the other.
It is not necessary to make use of drainage from the abdominal
wound.

Both of these methods have advantages over the use of the
serre-nceud. In them you have no stump to slough. Both are
extra-peritoneal just as much as the method with the serre-neud.
In the two methods the convalesence is shorter and there is less
danger of hernia. For these reasons I have no doubt that com-
plete extirpation or amputation at the level of the vagina will
supersede the method with the serre-ncBud.

Dr. J. M. Baldy : I shall have nothing to say in regard to
removal of the appendages, for I think that we all agree that small
fibroids can be successfully treated by this method.

I have, however, considerable to say in regard to hysterectomy.
I think, as the essayist tonight has said, one is apt to use that
method, and to consider it the best, which in his experience has
given him the best results. I was sorry to hear Dr. Noble speak
of extirpation of the uterus as extremely easy. Total extirpation
of the uterus is the hardest operation in the whole range of sur-
gery. I have come across nothing that has equaled the.difficul*
ties and the complications to be met with in the complete removal



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PHILADELPHIA COUNTY MEDICAL SOCIETY. 38

of the ateros from above. I do not believe that it will take the
place of the extra-peritoneal method of dropping the stump and
leaving the pedicle.

The extra-peritoneal method with the serre-noeud is the only
method the beginner should think of using; but those who are
skilled and are familiar with the anatomy, both normal and dis-
torted, will not rest satisfied in the failure with treating the stump
extra-peri toneally. The old objection to treating the stump intra-
peritoneally was hemorrhage from loosening of the ligature, which
was applied to uterine tissue. At present, no one applies the liga-
ture to uterine tissue. The ligatures are placed in the broad liga-
ment tissue as in the vaginal hysterectomy, and there is no danger
from hemorrhage if the bleeding is conti*olled before the wound is
closed. There is no more danger of sepsis than in the extra-peri-
toneal method, for if the operation is properly completed the stump
will really be extra-peritoneal. The after-suffering of the patient
is lessened to a great extent. The distortion of the ureter and of
the bladder is done away with entirely. With the extra-peritoneal
method it is necessary to keep the patient in bed six weeks to two
months, in order to guard against hernia. By dropping the stump,
the patient is out of bed as soon as after an ovariotomy, and there
is no more danger of septic poisoning, fistula, or hernia, than after
any exploratory operation. There is, however, more danger of
shock where the pedicle is dropped, for the operation is a longer
one. If the condition of the patient will not warrant keeping her
half an hour longer on the table, dropping of the stump should not
be considered, but the stump should be treated extra-peritoneally.
In regard to danger to the ureters, I have only once seen the
ureter in fifty cases, and have never tied it.

I would not agree with the statement that the best showing is
made by the extra-peritoneal method. I think that the time has
come when the statistics of the intra-peritoneal method fully equal
those of the extra-peritoneal. I have reported some twenty-seven
cases in which I treated the stump extra-peritoneally, and about
ten in which I dropped the stump, and my results have been
equally good.

Dr. 6. F. Baeb : I agree with much that Dr. Price has said,
and especially as to the advisability of early operation in fibroid
tumor. In many instances these tumors continue to grow, and
sometimes undergo malignant change after the menopausal age is
reached.



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34 SOCIETY PBOCBBDINOS.

My recent experience only confirms the opinion which I have
for several years held upon this subject. The majority of cases
upon which I have operated had either reached the menopause or
had passed it. The last case operated upon, last Monday, was a
patient forty-eight years of age, who had a large fibroid tumor
which had been growing for ten or twelve years, and which had
given rise to the ordinary symptoms of that disease, as hemorrhage,
pressure, etc. She was advised to wait until the menopause, but
when she reached that age the tumor increased rapidly in size,
especially so during the last year. The operation showed it to be
an edematous fibroid with a malignant appearance, I fear is sarco-
matous, although a microscopic examination has not yet been made.

Three months ago I performed a hysterectomy upon a lady
fifty-five years of age, for a growing fibroid tumor. The specimen
showed multiple fibroid degeneration of the uterus, one of which
was breaking down and was undergoing malignant change. This
and similar cases, a number of which I have had during the last
two years, convince me that we cannot too soon get rid of the
idea that the menopause cures these cases. I believe that where it
is determined that a fibroid tumor of any size exists, the patient is
safer if the uterus is removed. The teaching that fibroid tumor
is a benign disease, that it never destroys life,, and that if the
patient reaches the menopause she is safe, is erroneous. Even
where no symptoms are present, such as hemorrhage or pain, the
constant presence of a tumor induces such an unhappy mental
state, that, where the patient desires it, the tumor should be
removed.

My experience with o(>phorectomy in cases of fibroid tumor
has not been as encouraging as that of some of the speakers who
have preceded me this evening. Even if the ovaries and tubes have
been entirely removed, the tumors do not undergo atrophy, or do
it in such a slow manner that the patient is dissatisfied with the
result. Hemorrhage often continues, and pain and pressure are
not relieved.

Eighteen months ago I removed the diseased ovaries and tubes
from a patient who had a number of small fibroid tumors of the
uterus. The whole mass did not extend much above the superior
straight. I had hoped that the removal of the appendages would
cure the patient, and she was much improved for about six months.
She then began to bleed, and the hemorrhages recurred so
frequently and were so profuse that she again sent to me. Exam-



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PHILADELPHIA COUNTY MEDICAL SOCIETY. 35

ination at this time showed that the fibroids were growing.
Hysterectomy was then done, and she is well with the result. I
believe that hysterectomy by the method which I advocate, and in
experienced hands, is as safe, if not safer, than ovariotomy, and I
have no doubt that the patient is better, because she has gotten rid
of the tumor at once.

I was surprised at the position taken by Dr. Price this evening.
I had hoped that he would be willing to make what I regard as an
advance, and would report to us that he h%d at least tried this new
operation in one case, because I am firmly of the belief that it is
the most scientific method. I am not alone in that belief, for as
we have heard just now, other eminent operators are taking it up.
I have no doubt but that it will be regarded as the only practical
and safe method as soon as it is fully understood. This operation
leaves the cervix extra-peritoneal, as Dr. Noble has said, even more
so than by fixing it in the lower angle of the wound. It leaves
it in its subperitoneal or extra-peritoneal position just as the uterus
is anatomically. The incision is closed without drainage, the
parts left to heal primarily and without interference, and they do
so in every instance. The convalescence is shortened a month, at
least ; there is no distortion of bladder and bowel, and no after-
dragging upon the cicatrix.

Of course, this operation requires experience and skill, and
should not be undertaken by the beginner in abdominal surgery.
The way for a beginner is not tq begin with hysterectomy. He
should first serve an apprenticeship in the more minor operations
in this field. But this will apply to hysterectomy by any method,
for it should always be regarded as a very major operation.

Dr. Thomas S. K. Morton : I wish to say one or two words
about this intra-peritoneal operation. I had the pleasure of seeing
Dr. Baer perform it recently, and it was more or less of a
revelation to me. The operation was done by ligating the arteries
of the broad ligament on each side. The uterus and appendages
were then separated from the broad ligaments, and the cervix was
cut, leaving one-half or three-fourths of an inch of uterine tissue.
The broad ligaments then slipped down around the cervix, making
a straight line, which required no sutures. The operation did not
seem much more serious than an ovariotomy, although the incision
was longer and more surface exposed. •

Dr. Chables P. Noble : In regard to injury of the uterus, I
think that the danger is less by the method referred to by Dr.



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36 SOCIETY PROCEEDINGS.

Baer than by the nceud. By tying close to the uterus, there is less
risk of tying the ureters. In doing complete extirpation by the
method advocated by Dr. Polk, of New York, I think that there
is considerable danger of including the ureter in the ligature
around the uterine artery. In regard to the confusion of the
terms extra- and intra-peritoneal, I wish to emphasize the fact that
in both of the methods the stump is extra- and not intra-peritoneal.
It is extra-peritoneal, as the stump is under the peritoneum, and
the peritoneum is sewed over the stump. In the one case the
remnant of cervix, in the other the broad ligaments, constitute the
stump. It is as much extra-peritoneal as though the peritoneum
of the abdominal parieties were stitched around it on the anterior
abdominal wall. It is, therefore, an extra-peritoneal method of
treating the stump.

Dr. Prick : I look upon hysterectomy as one of the most
serious operations. I have had a series of 103 cases, and lost six



Online LibraryJ. A. (Joel Asaph) AllenBuffalo medical journal → online text (page 4 of 78)