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Prices of both hemispheres, the short incision and the radical excision must fall back where they belong, to the selected cases where they fulfill the indications, and which we now know are not so numerous as formerly imagined, for we have come to realize that in many cases the operation was too much, and in many not enough. The woman of to-day insists not only upon having a radical operation done successfully, but she also expects to be cured of her disease, with its accompanying pains, aches and discharges. The surgeon of exclusively great experience is positively not the best guide as regards operative indications. His dictum concerning technique and immediate results is invaluable; whether he cures his patients of their diseases he seldom knows. son of this is evident. He does not practice medicine or surgery in the ordinary sense of the word. He reigns supreme over a college amphitheater with its adjunct hospital, or he manages a large private sanitarium. Patients are sent to him by physicians who have learned of his great ability, and after a few weeks he sends them back cured of the operation, but frequently uncured of the disease. The doctor of one laparotomy always knows the result, both immediate and remote. A surgeon, of I should judge about three hundred laparotomies, in a discussion on this subject, menticned that his results had been very satisfactory, that he did not have more than a dozen women who occasionally wrote to him concerning bad symptoms of pain or discharge. How deceptive. Probably twice as many were writing or visiting some other surgeon, while a much greater number were at home nursing alike their sufferings and their loss of faith in the medical profession, and wishing their ovaries back.
The picture is a true one. A very reasonable proportion of my patients are complaining to me and a reasonable proportion of yours also, while you are listening to the same plaints, and quite an army are suffering in silence.
Salpingectomy, salpingo-oöphorectomy and oöphorectomy frequently fail to cure patients with peri- and para-uterine septic disease. Hysterectomy has of late years been found efficient in curing many cases that were still suffering after the first mentioned operations had been performed. The impropriety of leaving behind frequently the chief offender among the pelvic organs has become evident, and a great step has therefore been made in the cure of these disorders. The amount of sentiment wasted upon the emasculated uterus, as Dr. Polk calls it, has always seemed ridiculous. Under such conditions, it is simply a cloaca for the origin of hemorrhage, the accumulation of discharges, and the development of malignancy. Whether done abdominally or vaginally, this operation has a great future, and in spite of opposition has made wonderful strides because of the thoroughness of its curative effects. In this country it is only a few years since it has been performed with deliberate intent, and all its indications in view. It had originally been performed in an emergency, as a matter of expediency, when the destructive process made it almost a necessity. Péan guided by his great surgical genius, first performed it, in his anxiety to cure a patient who had remained un. cured after a salpingo-oöphorectomy. To-day it is an established procedure, and the position of advanced, observant gynecologists, who are not hampered by tradition or custom, or afraid of their own stubborn, dogmatic expressionsin the past, can be stated as follows: "In every operation for septic diseases of the female generative organs which demands the removal of the tubes and ovaries, hysterectomy should also be performed, unless there are plain contraindications forbidding it.” This means that this operation which ten or fifteen years ago was never done, which five years ago was rarely, and three years ago only exceptionally done, now, should be the rule. It does not mean more mortality, and it does mean more perfect and complete cure. After you have laid violent hands upon
the ovaries, it matters not what becomes of the uterus. This tragic cry that an organ should never be removed without cause is all nonsense, in view of the fact that it has been proved innumerable times to be an element of mischief. This is true conservative surgical treatment in pelvic septic diseases.
But, gentlemen, before you touch the ovaries, then is the time for the display of your sentiment.
Whatever men may say, women do recover from salpingitis and pyosalpinx from ovaritis, peri-ovaritis and ovarian abscess, from cellulitis and phlegmon of the broad ligament, whether these be of the catarrhal, puerperal, or gonorrheal variety.
And they sometimes recover entirely and completely, so that this contingency, even if infrequent, must always be considered in forming surgical conclusions. Where surgical measures are considered proper and advisable, much depends upon the character and malignancy of the infectious material and the stage of the disease and amount of destructive process already present.
Having expressed the opinion that total ablation of the internal genitals of women in some cases presents the highest type of conservative work in the fact that it saves life and suffering, I beg leave to present for your judgment the result of some work I have done in the line of conservative surgical measures on the old lines of vaginal section. I will not weary you with extracts from the history of vaginal sections and punctures, written since time immemorial. What I have done is neither original nor a revival of the teachings of forgotten masters.
Pus sacs or serous sacs, or exudated masses have been punctured aud incised in all manners and with all variation of instrumentation by surgeons for all times back. We have only to draw your attention to the writings of Laroyenne, Landau, Mundé, and innumerable others. Some have used the exploring needle and a trocar, emptied the cavity of its contents, frequently using irrigation. Others have introduced metrotomes through the trocar. Others, again, have incised directly and largely the septic focus or penetrated these pelvic cavities with different varieties of cautery knives. There is no need of mentioning authorities upon this subject for the task would be interminable. It means simply that surgeons, recognizing the presence of inclosed septic material, have followed the general surgical rule of emptying, washing, and draining
Sinclair, Mundé, and others advise free incision of tubes which are adherent to the peritoneum of Douglas' sac, per vaginam, subsequently washing out the empty tubes. Shröder has repeatedly employed this method in reaching adherent pyosalpinx. And so with many others, among whom I might mention particularly Reclus, Gusserow, Bouilly, Formento, of New Orleans, Cabot, of Boston, More-Madden, etc. Vuilliet (Gazette médicale de Paris, October 29, 1892) says that he has not done hysterectomy or abdominal section in suppurating pelvic disease in two years. In eighteen cases he has adopted Landau's method without accident, loss, or relapse, usually using a trocar, which, after carefully locating the sac, he plunges into the cavity. If no liquid appears he makes another puncture. He repeats this at the end of ten or twelve days; if the fluid reaccumulates he injects after the second puncture one to two and a half drachms of bichloride solution. If fluid returns after three or four punctures, he then incises and tampons with iodoform gauze, using a knife like a metrotome, slipping it upon the trocar. This is substantially the method described and practiced by Laroyenne and Landau, both of whom have written masterly treatises upon the subject. Laroyenne and Goullioud, his pupil, claim an important place in the treatment of pelvic inflammations for their method, which opens up largely by the vaginal route parametric chronic collections and holds them open until cicatrized. Their method applies to the diverse Auid collections in the pelvis, tubal dilatations, serous or purulent effusions in Douglas' sac, retrouterine hematoceles, parametric abscesses, etc. It suffices, they say, that the collection, large or small, should be clearly perceptible to bimanual palpation and be an infiammatory mass. It is not necessary to get fluctuation, which in the pelvis is difficult to make out. The immediate result is considerable ease, and eventually complete cure even in multiple pus focuses. Distant results, they report, have been almost constantly satisfactory. Noticeable in this is the length of time in which note is made of the patient's condition. Laroyenne records in regard to ulterior condition all the cases which have been seen at least eighteen months after operation. Four women who had been operated upon afterward conceived and bore children.
Ablation of the annexae remains as an ultimate resource in case pain continues; then it is simply salpingo-oöphorectomy without
The greatest recommendation of the operations of these various men is its lack of danger. Goullioud gives a series of seventy cases, with one death occurring twenty-eight days after operating, due to an abdominal rupture of an unexplored pyosalpinx. He eventually reports another series of sixty cases, with one death, due to secondary operation for artificial anus, the patient having afterward been operated upon abdominally, and a fecal fistula remaining.
Edmund Blanc, another pupil of Laroyenne, publishes a series of twenty-seven cases of chronic peri-uterine inflammation with serous, hemorrhagic, or purulent effusions. Many others, however, speak of the danger of these incisions and punctures, particularly the danger of wounding the ureters or the uterine arteries. Hoffmeier speaks of these dangers, and says it is necessary to use sharp or puncturing instruments; also mentions the difficulties encountered when one cannot exactly locate the pus sac.
There is no further need of multiplying these quotations, for not only does literature abound with them, but it is a subject with which you are all familiar, and the procedure is one which you all, at one time or another, have employed. Nevertheless, it seems desirable that in this age of wholesale ablations these simpler and often successful minor methods should not be lost sight of. Personally, I have frequently drained pus collections in the pelvis through the vagina, these pus collections being the result of chronic inflammatory conditions. It seems only reasonable to suppose that such operations may be successful, even in the most chronic forms of pyosalpinx. What happens in such cases ? Septic material traveling up the Fallopian tube, when the process is not too rapid, finds itself arrested at the abdominal opening by a closure of the ostium abdominalis. An abscess cavity is developed in the walls of the tube proper. After a time the uterine end becomes closed, and then we have an independent pus sac, not communicating with either the serous or the uterine cavity. This may rupture into the folds of the broad ligament and work its way toward the vagina. If widely opened and drained and packed, after a time all the socalled pyogenic lining membrane disappears, granulations fill the gap, the Fallopian tube becomes obsolete, and the patient is cured.
One of the reasons of failure of many men in the past is due to forgetting to pay the proper attention to the condition of the adjoining uterus, this organ being left unattended to and frequently giving rise to further trouble. I do not mean to propose, as some most enthusiastic followers of these various measures have done, the employment of this vaginal incision as a substitute for more radical and complete work, but I am simply endeavoring to impress you with the absolute necessity of discrimination, and, with that intent, I quote the success, that some others have attained in curing even the most serious forms of trouble by conservative measures.
In treating chronic cases of inflammatory septic disease it is necessary to make sure that a patient is incurable by milder measures before resorting to the radical operations.
In the first part of this paper I have drawn your attention to the fact that many patients were cured of the operation while not cured of the disease, and that only the most complete ablations will suffice to cure some patients. But while we may, in the present state of our knowledge, be obliged to resort to the most serious radical operations to cure the patients entirely and properly, our minds should be constantly alert for the purpose of discovering methods by which the severer operations may be made available. The difficulty of understanding and analyzing pelvic inflammatory diseases becomes self-evident when we contemplate the many varieties of forms which the disease may take. A simple so-called catarrhal invasion of slow progress following the mucous channels may result in a chronic hyperplasia, sclerosed condition of the uterus, tubes and ovaries, producing a most serious deterioration of health, and yet giving but very moderate evidence of its serious