[Reprinted from the American Gynaecological and Obstetrical Journal for October, 1894. DISCUSSION OF METHODS IN PELVIC SURGERY* Joseph Price, M. D., Philadelphia. Mr. President : The following brief report of cases I present chiefly for a discussion of operative methods. We all recognize that at present there is no uniform concensus of opinion in either opera- tive methods or technique. A few years ago confidence in some pro- cedures now questioned was absolute, and the results were then thrice better than now. Case I. is that of a multinodular fibroid removed from Mrs. P., aged thirty-eight; no children ; two doubtful miscarriages. She gave a good history of pelvic inflammatory trouble of long standing. The pain and tenderness had incapacitated her from making a living. Defecation and the passage of flatus was difficult. Examination showed perfect fixation of the tumor and also an- chorage of the pediculated fibroid above. The removal of this tumor, free and fixed portions, required a careful dissection from the umbilicus to the floor of the pelvis. The omentum was tied off; adhesions of small and large bowel freed; broad adhesions bridging the pelvis and contents of pelvis freed ; bladder adhesions to fundus, tubal and ovarian adhesions on both sides freed ; tumor delivered and removed. The method adopted here was that of the extraperitoneal treatment of the stump. Re- covered. While the adhesions were extensive and strong, they were strictly healthy. It is always important in such cases to free all visceral ad- hesions and- to leave the viscera in as normal a position as possible before closing the incision. I am satisfied that some deaths and un- manageable distention following similar operations are due to a want of care on the part of the operator in completing his work. This fact I have demonstrated repeatedly in doing over incomplete work of * Read before the Obstetrical Society of Philadelphia, September 6, 1894. 2 Joseph Price, M. D. others, also in the nil mortality of my own hysterectomies. Some years ago I completed a series of forty-three hysterectomies without a death ; lost the forty-fourth by an accident. I lost a hysterectomy last Au- gust ; none since. The present series is now large, and I am con- vinced the operation is quite as safe and sure as ovariotomy; the pa- tients seem to do even better. While presenting this specimen, Mr. President, I desire again to call attention to a few points interesting and important in the natural history of these growths. The specimen presented is typical of the multinodular variety of hard growths. I regret that I have not for contrast one of the smooth myomatous variety. They are not uncommon, but not quite so com- mon as the multinodular; rarely are they found complicated by tubal and ovarian disease ; not prone to cystiform or malignant degenera- tion. Malignancy, if found at all associated with the growth, is com- monly found about the coecum or sigmoid, and seems to be due wholly to pressure. I have found four cases of this nature in my own work ; malignancy of the large bowel on the right in two, on the left in two. I wish again to refer to the causal relation which tubal and ova- rian disease bears to the multinodular variety of uterine fibroids. I have repeatedly urged the removal of tubal and ovarian disease in the absence of uterine growths; the patients have delayed or refused, re- turning to me two or four years later with a uterus studded with fibroids, the tubal and ovarian disease more marked. This has occurred repeatedly in married and unchaste women under the age of thirty. The smooth, symmetrical varieties of myoma have occurred in single or clean women free of tubal and ovarian disease. While a few gynaecologists may deny these statements, my reply will simply be that they have failed to recognize so many things of pathological and surgical importance in their own work and that of others, deny the existence of some troubles, cling to the myths of an- cient pathology, and contradict themselves and all they have said every four months, making it scarcely worth while for scientific and earnest, truth-seeking men to pay attention to anything they do or say, except sufficient to prevent it doing mischief. Here, as in about all multinodular fibroids found in young women, we find tubal and ovarian disease with a history of specific trouble. I unhesitatingly state here that gonorrhoea bears a strong causal relation to early fibroid disease in prostitutes and the colored population of our country. I have a group of six or more white women now suffer- Discussion of Methods in Pelvic Surgery. 3 ing from marked tubal and ovarian disease with multinodular fibroids of the uterus ; they are all young—under age for the development of fibroids ; none of them have ever been pregnant, and they are all the wives of drummers. Again, I have a few that are the wives of doc- tors—of course professional pride would make me hesitate. We have had some very sweeping statements in regard to prophylaxis in tuber- culosis, epilepsy, cholera, etc.—in all contagious and transmissible dis- eases. I am convinced, from a long and rich experience with the sequelae of gonorrhoea, that it is of much or more importance to look after this neglected and dangerous disease in clap-stricken men ; they are dangerous objects in a refined community, morally and physically, and are a lasting menace to the health of females. Case II.—Mrs. M., aged thirty-one years, white, married, one child, three miscarriages, a sufferer for nine years. Many attacks of pelvic inflammatory trouble confining her to bed for periods of months. All this trouble followed the closure of the cervix eight years ago. Not pregnant since closure of the cervix. Some four months ago an ab- sent period was followed by great pain and tenderness, marked anae- mia, and emaciation. I found a boggy tumor extending nearly to the umbilicus. Upon section I found omental and bowel adhesions above and the uterus pushed far forward. When I freed the omental and bowel adhesions I evacuated a quart or more of decomposing blood- clot. The irrigation was a very copious one, using five large pitchers of water, following by glass drainage. The clot had become quite offensive. These observations are wholly clinical in nature. She has made an easy recovery. Surgery beyond irrigation and drainage would have destroyed her. Case 111.—March 31, 1894. Mrs. S., white, aged twenty-nine. Two children at term, both complicated labors, dead children deliv- ered. Before her first conception she was sent to me for some ob- scure trouble on the left side. I recognized tubal and ovarian dis- ease on that side and advised local treatment. She conceived and went to term. The labor was complicated by a malpresentation requir- ing a high application of the forceps, and she was delivered of a still- born child. About two years later she again conceived, went to term, and was attended by a midwife. The labor was complicated by a breech pres- entation and the patient was delivered of a stillborn child. Three days after delivery, and two weeks before the section, she had pelvic pain and chill followed by high temperature. 4 Joseph Price, M. D. Her family physician found a swelling on the left side higher than the region of the left ovary; this increased rapidly with greater tenderness and pain, temperature ranging high. Section and removal was decided upon. The position of ovary and tube indicated prolonged and high fixation ; the ovary had formed an enormous sac to the left and above the sigmoid, extending up to the kidney, leaving an enor- mous hole at that location after its enucleation ; it probably contained thirty ounces of pus. The history of this case is a beautiful fortification of the numerous allusions and demonstrations with specimens of dermoids and pus- tubes I have made to the causal relation they bear to post-puerperal trouble. I have seen great numbers of patients ill or dying of so- called puerperal fever. Some of these conditions were due to small suppurating dermoids, others to old, chronic unilateral tubal disease or small cystomata. There is no theory about these statements, but they are simply the result of numerous experiences at the operating table. On the right side the tube is patent and the ovary free ; later, oc- clusion may occur with retention. Curetting is commonly practiced in just this class of cases for en- dometritis ; if this disease exists, in all probability conception will not occur. In dealing with these cases surgically for years, I have made a most careful study of the masses (right and left), of size, position, fixation, and outline ; quite a number I have watched for months or years be- fore the patient would submit to the removal. After the removal I have made a careful study as to the possibility of such pus conduits discharging their contents through the uterus, lam now satisfied that it is the least frequent source of spontaneous evacuation—that they will in all cases open through the large or small bowel, bladder, va- gina, or other points, before discharging through the hardened, thick- ened, contracted uterine extremity of the tube. I have repeatedly made the statement that pus-tubes never discharge through the uterine cavity ; now I desire to repeat it with unqualified emphasis. This state- ment has been recently and repeatedly challenged ; first, by a class of men who ought to know better ; second, by a class that have had neither practical experience nor observation justifying the challenge. They now claim in large numbers that the globular and sausage-shaped masses diminish in size under manipulation and discharge through the uterine cavity. Others that a great many abscesses discharge spontaneously through the uterus, vagina, or rectum, and are thus Discussion of Methods in Pelvic Surgery. 5 completely cured ; through the vagina or through the rectum is a common source of slough, but these are delayed, neglected, and unfor- tunate cases, and are not thus completely cured. Now I challenge this class of men to demonstrate, before and after operations, to competent spectators the truth of the statement. Some of them tell us, “ I have pressed it out in many cases.” The cases are sufficiently numerous to settle this question at any time to the entire satisfaction of all gynaecologists. First, they can squeeze it out by manipulation. They can take a typical case, or fifty of them, compress or manipulate freely the tortuous distended tubes or pus conduits and ovarian abscesses, and not a drop of their con- tents can at any time be expelled into the uterine cavity. Fingers or the Sims speculum may be placed in the vagina while this is going on, and, if successful, an ocular inspection can be made. Again, I chal- lenge them to make the demonstration after the removal of the pus conduits, provided the tubes have been removed at their very roots. Neither demonstration has as yet been made. They have made all sorts of theoretical claims for the curette, gauze drain, dilatation, irri- gation, manipulation, etc , without the least ground in fact to justify their claims for drainage of pus-tubes. Some of these men have never seen a pus-tube ; others have never seen an abdominal section of any sort. Case IV.—Mrs. A., aged thirty-nine, seven children, one miscar- riage. For the last year emaciation has been marked. Intraperito- neal nodular growths were recognized six months ago. The growth was rather rapid. Pressure symptoms well marked, with some ascites. Diagnosis.—Physical signs those of multinodular fibroid. Two large projecting, resisting masses extending well up into the renal re- gions. Physical appearance was that of a woman suffering from ovarian disease. Our diagnosis was multinodular fibroid. Section, August 31, 1894.—Double ovariotomy. Drainage. Pathological Condition.—Large sarcomas of both ovaries, kidney- shaped and size of small adult head. Numerous adhesions—parietal, pelvic, and visceral. General invasion of bowel and mesentery. Case V.—Miss R. M., aged twenty-four, colored. Admitted Sep- tember 4, 1894. Diagnosis.—Double pyosalpinx and probable ovarian abscesses. Subjective symptoms well marked. Severe pelvic pain intensified by locomotion. Painful and difficult defecation and micturition. Fe- brile disturbance with rapid emaciation. Objective signs. Tortuous and symmetrical, painful fixed masses completely filling the pelvis. 6 Joseph PiPce, M. D. Section, September 5, 1894.—Huge pus-tubes and ovarian abscesses enucleated ; there had been a general descent of pelvic viscera. A small portion of ileum strongly adherent to pus-tube on the right low down, the most common point for small bowel adhesion. More than twenty times in the last three months’ work I have found the ileum adherent on the right side, varying from one inch to twenty inches. The appendix was also found strongly adherent and disorganized. In a good number of neglected cases—neglect due to the so-called con- servative papers and discussions—I have found the head of the caecum, ileum, and pus-tube and ovarian abscess strongly adherent. On the other side the sigmoid in puriform accumulations strongly adherent. Surgery for puriform collections at present has become much more complicated than it was a few years ago. Mortality has also increased- The number of incomplete and abandoned operations is swelling. Operators are weakening on the old, tried, and well-tested procedures, trying numerous other methods that have absolutely nothing to recommend them. The vaginal method for the removal of diseased appendages is a dangerous and incomplete procedure. I can not conceive of an oper- ator with varied experience in the removal of diseased appendages by abdominal section trying a vaginal operation. lam further con- vinced that those who do the vaginal operation fail to recognize the extent and true nature of complications, do incomplete work with a high mortality, and continue to do incomplete work by the vaginal method. They occasionally remove a little healthy uterus crowded down by puriform disease. The healthy little uterus removed, rotten tubes and ovaries remain. The whole subject, once so simple, the re- sults so perfect, has again become confused and complicated. The Philadelphia Obstetrical Society has probably done more to establish the true pathology, and bring about good surgery, than any other society in existence, excepting only the British Gynaecological. Numerous criticisms have been made of our pointed discussions. The Society could do the world the greatest possible good by devoting the coming ten meetings wholly to the discussion of pelvic inflammatory troubles.