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been regarded by Emmet as the result of a circumscribed cellulitis.

For several years I have doubted if this was a cellulitis at all, not being able to understand why a limited area of cellular tissue so situated should be involved in inflammation, or why such an inflammation,if it existed, should refuse to yield to our treatment. In some instances I have thought I could make out the ovary, in others an inflamed lymphatic gland; in other cases still I have imagined that an inflamed lymphatic canal lay under my finger close to the uterus. These same doubts have occupied the minds of others as well as myself, yet no satisfactory explanation of the subject was given.

Quite recently, since abdominal section has become so common for the removal of the uterine appendages, a good deal of light has been thrown upon the case. Moreover, the pathologists have taken the matter in hand, and the pelvis, in which these thickenings and circumscribed areas of tenderness were found, has been subjected to thorough examination after death.

The results of these studies, though somewhat meager and not altogether satisfactory as yet, go to show that it is not the cellular tissue which is involved in inflammation, but that "the greater number of these indurations are situated high up in the broad ligaments, and consist of cicatricial masses, mostly confined to the peritoneum, of tubes or ovaries surrounded by old adhesions, or occasionally of an imprisoned knuckle of intestine."* Peritoneal exudations and not cellulitis, as Emmet thought!

I trust you will not think I am here entering into a discussion of things unimportant in their nature, or that I am taking you into the refinements of gynecological science. My own estimate of the matter is that we are here studying the most interesting, the most difficult, and at the same time the most vital, question that has ever absorbed the attention of the gynecologist. The pathology of uterine diseases within a few years past has undergone complete revision; the doctrines of Bennett and his contemporaries have been completely *The Exaggerated Importance of Minor Pelvic Inflammations. By Henry C. Coe, M.D., M.R.C.Ş.

overthrown, and we are beginning now to realize that, while every part of the genital organs may suffer lesions peculiar to itself, the gravest forms of disease in a large proportion of cases lie not in the uterus itself, but in the ovaries and tubes, to which, physiologically speaking, the uterus is but an appendage.

In all of these we must remember that the application of remedies to the neck of the womb will be of as little avail as would the use of caustics or iodine to the head of the penis for the relief of a disease located in the testicles or other portions of the male sexual organs.

The treatment now proposed and practiced for intractable disease of the ovaries and tubes is the removal by the knife. Like every other innovation in medicine, this has met with strong opposition, and a bitter controversy has arisen. I do not know that the opposition in this case is based upon the ground that the treatment is not rational and proper, but rather that it has been resorted to too frequently and unnecessarily. It may safely be admitted that removal of the appendages has been done in this country as well as in Europe, very many times, when relief might have been obtained by other means. This was to be expected. We are ignorant as yet of many things which pertain to the diseases of the appendages. The diagnosis of these diseases is often doubtful, and even where ovarian or tubal disease is known to exist, the lines have not yet been drawn between cases requiring the radical operation of removal and those which may be cured by milder methods. Errors will of course be committed, but these furnish no ground for condemnation of the operation or for harsh criticism and abuse.

Leaving now the consideration of the advancement which has occurred in uterine pathology, I will invite your attention to the rapid strides which have been made during this short period of twenty-five years in surgical gynecology. Twentyfive years ago this art could hardly be said to have sprung into existence. Now I point you with pride to those well-established, if not thoroughly perfected, operations which have been devised to repair the injuries done in parturition to the pelvic floor and the vaginal outlet; also to the surgical pro

cedures on the vaginal walls for the cure of prolapsus uteri ; and in the same connection I may mention the operation for the repair of lacerations of the neck of the womb.

Within this period also the cavity of the womb has been invaded, and measures and instruments have been perfected for the removal of polypi and submucous fibroid growths. But the crowning glory of gynecology lies in having opened up to science an entirely new domain. I refer to abdominal surgery. All those great operations in the abdominal cavity for the removal of the spleen, of portions of the liver, of tumors of the kidney, for resection of the pyloric end of the stomach, for the removal of stones from the gall bladder, for hysterectomy, for extra uterine pregnancy, are the legitimate offspring of the operation of ovariotomy, which I need hardly remind you was first done by Ephraim McDowell of Kentucky. In this connection I must not fail to remark that this period which we are reviewing has seen the revival, the growth, the development to perfection, of the operation of ovariotomy. Though a few operations had been done in Kentucky by McDowell, and various surgeons in England had operated from time to time, in 1873 Dr. Thomas Keith of Edinburgh wrote as follows: "Till 1858 I could find nothing whatever, anywhere, to encourage, but everything to deter one from attempting it." In the language of Spencer Wells: "Up to 1858 it looked as if it might prove no more than a withering gourd. But by 1865 its root had stuck firm, its stem stood erect, its branches were wide and strong, known and sought as a refuge by the sick and dying. That it was no withering gourd has been proved by all that the world has since seen. Thousands of perishing women have been rescued from death; many more thousands of years of human life, health, enjoyment and usefulness have been given to the race; and to all future victims of a malady, before inevitable in its fatality, it gives consolation, hope, and almost certainty of cure."*

These are the words of a man, to whom, with the assistance of Thomas Keith, we are indebted for the revival of ovariot

*Revival of Ovariotomy and its Influence on Modern Surgery. Second Edition.

omy, and they were penned by him after he had completed that great surgical monument and magnificent achievement -one thousand ovariotomies!

It may justly be said that modern gynecology is more indebted for its growth and progress to the genius and influence of Marion Sims than to any other individual.

About the time which I have taken for my starting point in this review, Sims was beginning to establish himself in New York. He had already published his speculum to the world, and demonstrated the value of his method of treating vesico-vaginal fistules. A great and growing interest was then beginning to be awakened in gynecology under the teachings and brilliant achievements of this remarkable man. Dr. Gaillard Thomas says: "His labors constitute an era in the progress of gynecology. There is no more certain of appreciating the effect of light than by withdrawing it and marking the degree of darkness which results. If all that Sims has done for gynecology were suppressed, we should find that we had retrograded at least a quarter of a century."

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Another distinguished writer, Dr. Van de Warker, says: "It does not appear to be over-praise to say that in the death of J. Marion Sims the art of gyniatrics closed the formative period of its history. He found it crude; he left it an art as nearly perfect as any in the whole range of surgery." As we look around us to-day we are constantly seeing something to remind us of this great man. If you go into that noble institution, the Woman's Hospital of the State of New York, you see Sims in all the methods and all the instruments employed there for surgical work. That hospital itself is his work. Without Sims it would not have been built, at least in our day. Toward the close of his life he was giving the greatest part of his time to the study of abdominal surgery. Had that life been spared longer there is every reason to believe that his achievements in this branch of surgery would have been brilliant.

Sir Spencer Wells in his chapter on Tumors of the Liver and Gall Bladder, remarks that "Thudichum and Handfield Jones had stimulated the ambition of their surgical brethren; but it was not until the example of Marion Sims, and the

attention excited by the very remarkable paper which he published in the British Medical Journal in 1878, that the present generation of surgeons entered upon the path which he opened for us. Sims' patient was forty-five years of age. He removed from her distended gall bladder twenty-four ounces of fluid and sixty-six stones. He then cut away part of the gall bladder and sewed the other part to the abdominal wall, thus forming a biliary fistula. After death on the ninth day sixteen more stones were found in the gall bladder."

Then again the same author on the Operative Treatment of Peritonitis, after alluding to his own case of Tubercular Peritonitis in 1865, cured by abdominal section and removal of fluid; and to Marten's curious paper in Virchow's Archives, two cases of empyema abdominis treated by abdominal section, adds, "Cases may be found at long intervals, in the medical journals bearing on these questions, but the first really important contribution is a paper by Marion Sims in the British Medical Journal, 1881-1882, on the treatment of Gunshot Wounds of the Abdomen in relation to Modern. Peritoneal Surgery. In his usual strikingly interesting manner Sims argues that ovariotomy is the parent of peritoneal surgery; that other wounds of the peritoneum follow the same course as those made by the surgeon's knife in ovariotomy; and that in all, septicemia is the chief danger."

In concluding this subject I may say that it is almost impossible to overestimate the influence exerted by this one man in originating, developing and maturing modern gynecology. When we come to study it closely we shall find that there is scarcely any portion of it which has not been illustrated by the light of his genius. Twenty-five years ago gynecology stood in the relation of a kind of vermiform appendix to obstetrics. I do not exaggerate when I say that the relationship was not a whit more respectable than this simile conveys. Now it has become a separate and distinct branch of science, demanding all the time, and all the talents, and all the enthusiasm of its followers. This is observable from the fact that it has been made a distinct chair in many of our colleges. In America and Great Britain it has been separated from obstetrics in practice. Journals and societies VOL. VI-34

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