EVOLUTION AND REVOLUTION IN PELVIC SURGERY. * BY H. D. NILES, M. D., Pelvic and Abdominal Surgeon to the Holy Cross Hospital, Salt Lake City, Utah. As the anxious traveller, perplexed by a multiplicity of directions, finds it well to occasionally halt and, referring to his map, again fix in his mind his starting and objective point, and the route over which he has travelled; so may we find it advantageous to turn from the bewildering mass of contradictory opinions of to-day and, in a study of the principles that have guided us thus far in our progress, find light to shape our future course. The past five years have been most prolific in the production of new methods of diagnosis, treatment, technique, etc. Many questions of the highest importance to those who essay to do pelvic and abdominal surgery are being warmly and ably discussed all over To memorize all these details, these arguments and these methods would be as unwise as it is impossible. What we need more than a mind overstocked with vague ideas of numerous methods is a clearer idea of those underlying principles which are or should be the foundation of all methods. Unless we are well grounded in our knowledge of these principles we will not be prepared to pass intelligent judgment upon questions daily arising in our practice, reading or discussion, and still less to originate a method of procedure ourselves. These principles are precisely the same in pelvic surgery as those that guide us in surgery in other *Read before the Utah State Medical Society. parts of the body except as special physiological or anatomical peculiarities modify the pathology of intraperitoneal diseases. In theory these principles are generally accepted, in practice we are prone to forget or disregard them; and not infrequently we find ourselves over-influenced by clinical evidence, statistics, weight of authority, symptoms, established customs, etc., instead of being led by our mental picture of the pathological conditions we hope to correct. I trust you will not consider me presumptuous in recalling these well known, but to my mind unappreciated, facts, or the time of this association wasted, if to en.phasize their importance and attempt to estimate their influence as factors in the evolution of this branch of surgery. From long before the beginning of the Christian era until 1809 the treatment of disease within the peritoneal cavity was either purely symptomatic or at best based upon a speculative pathology. Public sentiment as well as professional judgment ruled that the peritoneal cavity should not be invaded by the surgeon's knife; and actual conditions of disease and the means of relieving them could only be guessed at by outward signs and symptoms. In all ages and with all people faith in medicine seems to be in inverse ratio to their knowledge of pathology. The more exact their knowledge of pathology the less their faith in medicine. With no knowledge. of pathology the treatment during all these years was exclusively medicinal or mechanical. In spite of these facts the symptomatic treatment of those days bears a striking and suggestive resemblance to the medicinal one advised in our text books of to-day. About 400 B. C. a treatise on gynecology in three volumes supposed to have been written by Hippocrates describes metritis, menstrual disorders, displacement, etc. Soranus in the third century B. C. gave a pretty accurate description of the female sexual organs based, he says, on dissections of human beings and not monkeys. He also seems to have understood the use of the speculum and uterine sound. In the sixth century A. D. Aetius describes the vaginal speculum-cylindrical, bivalve and trivalve, sponge tents, medicated tampons, pessaries, uterine sounds for restoring the position. of the uterus, etc. Our knowledge of pelvic cellulitis dates back to this time, and its treatment by hot injections, medicated pessaries, poultices, etc. Caustics for ulcers of the cervix, astringent injections of alum, etc., for vaginitis, even lamb's wool tampons can also claim the same antiquity. Linseed poultices and hip baths were prescribed for the same symptoms for which they are advised today, but by some oversight iodine was not discovered until 1812. Many of these old instruments are now on exhibition at Genoa and are not very dissimilar from those employed at the present time. It is possible that excision of the uterus was practiced by the ancient Greeks; but we have no authentic evidence to prove it. There are also reasons for believing that laparotomies for intestinal obstruction were done in the latter part of the eighteenth century, "but with such results as to incur universal condemnation," and "even at the present time, in spite of the great advance in abdominal surgery and the increased certitude in diagnosis, there are many medical men who would consider it no discredit to stand by with folded hands while a patient is dying of an unrelieved internal strangulation of the bowel." (Greig Smith). Thus we see that during all these years, notwithstanding their professed allegiance to the principles of rational medicine as enunciated by Hippocrates and promulgated by Galen and his followers, their practice was of necessity empirical, and very like that endorsed by those men of to-day who denounce empiricism as a doctrine, but who ignore pathology as a guide in practice. In the early part of the present century an event occurred which exercised a more potent influence in the evolution of our knowledge of intraperitoneal disease than the combined labors of all the preceding centuries. On the third of December, 1809, at Danville, Ky., Ephraim McDowell invaded the peritoneal cavity and successfully removed a large ovarian cyst. This was the first ovariotomy on record. His account of the operation was not published until seven years later, and was then included with two other cases upon whom he had operated. In all he performed thirteen ovariotomies, with at least eight successes. In the light of intervening events the work of this pioneer abdominal surgeon must be regarded as little less than marvelous. Alone, with only a local prestige, in an obscure town, in violation of all past customs and existing opinions, he not only had the genius to conceive, but the skill and moral courage to execute a plan of procedure which has stood the test of eighty-seven years of experience and progress. When we recall that this occurred in pre-antiseptic days and before anesthetics were known, with none of the advantages of a modern operating room, trained assistants and nurses, and in the face of a universal belief that to enter the peritoneal cavity meant death, we scarcely know which to admire most-the genius, skill or daring of the operator. His description of the operation which has made his name immortal, occupied but a page in the journal in which it was first printed. Brief as it was it has been said to have added 40,000 years to human life. A nine-inch incision was made just external to the left rectus muscle, through the abdominal wall-fallopian tube ligated near the uterus and the sac opened and emptied. The sac was then amputated and the incision closed with interrupted suture strengthened with strips of adhesive plaster. No drainage was used, but the ligature about the fallopian tube was brought up to the lower end of the wound. The tumor weighed about twenty-five pounds. Five days later the patient was walking about. She made an excellent recovery and lived in good health for many years afterwards. On July 25, 1821, Dr. Nathan Smith, of Yale, and on May 23, 1823, Dr. Allen G. Smith, of Danville, Ky., each operated successfully. Then came J. C. Warren, the Atlees and others. Up to 1863 117 ovariotomies had been performed in America with sixty-eight recoveries. In England, up to 1850, thirty-three operations had been recorded with twenty-one successes. Then came the achievements of Spencer Wells, Baker Brown, Thomas Keith, Martin, Schroeder and others with their modifications and improvements, until to-day ovariotomy may be regarded as the most successful major operation in surgery. Nor was the application of surgical measures confined alone to ovarian tumors during this time. The impetus given and the knowledge gleaned in this line was extended to all large or malignant tumors and easily recognized grave lesions, In 1839 Sedillot performed gastrostomy for malignant stricture of the oesophagus, followed in the fifties by Fenger, Forester and others. In 1828 Blundell recorded four cases of hysterectomy for cancer. In 1853 Washington Atlee read a convincing paper on the surgical treatment of uterine fibroids. Dr. Kinlock, of North Carolina, operated for gunshot wounds in 1863. Only six operations were recorded up to ten years ago. Spencer Wells opened the abdomen in 1862 for tubercular peritonitis. Cholecystotomy was first performed in 1867 by Dr. Bobbs, of Indianapolis, although it had been proposed and discussed long before this time. In 1860 Walcott, of Milwaukee, removed a cancerous kidney. From this, it will be seen that considerable progress was made during this period, 1809-1872; but it was made in a single line limited by a scanty knowledge of pathology and the high mortality. belonging to the abdominal surgery of pre-antiseptic times. Outside of this narrow line no advance worthy of note had taken place. The old empirical treatment practiced for twenty centuries had not been materially modified. Actual conditions were still matters of conjecture; treatments were experimental, opinions were supported by citations of cases. Substantial progress can never occur in any department of science as long as actual conditions are purely a matter of conjecture, methods entirely experimental and proofs limited to the citing of examples. Early in the eighth decade of the present century came Lister's great discovery, and later the knowledge of the microbic origin of all inflammatory lesions, which, combined with the magnificent work of Tait, Hegar, Battey and others, has revolutionized our conception of intraperitoneal diseases and their treatment. The story of the evolution of pelvic and abdominal surgery since 1872 reads almost like a romance, recording as it does how a few men of genius, brave and true to their convictions, struggling against a public and professional sentiment and prejudice founded on time honored customs and practice, risking their reputation, even their lives, in their devotion to this cause, finally achieved a brilliant victory and won for followers the thinking element of the whole world and made mankind forever their debtors. TOLE 1. 9611-10 In 1872, within a few months of each other, Tait, of Birmingham, England, Hegar, of Germany, and Battey, of Rome, Ga., each working independently, removed the uterine appendages, The objects they sought to attain in each case were quite different; Tait operating for inflammatory lesions of the tube and ovary, Battey, in the hope of bringing on the menopause might relieve the patient of obscure neuroses; and Hegar for the purpose of controlling the hemorrhage of uterine fibroids. Our present conception of pelvic pathology and appropriate surgical interference is very different today, but it began and grew out of the work of these three men, un It seems to me to be an established custom that radical departures for the better in any line shall never be fairly investigated u til their authors shall have been sufficiently abused and ridiculed. The abuse and ridicule are always attended to promptly. A fair judgment often waits on a tardy investigation; but rarely has the feeling been so intense and so universal, and the persecution so bitter as that incurred by the work of these three ree men. For a ti time they were ostracised by their professional brethren and society, and even their lives threatened by the laity. Men who were unwilling to investigate and unable to judge were quickest to doubt their sincerity and ridicule their logic. Time produced fairer and abler judges; and to-day we know that to their unwavering loyalty to their convictions, and undaunted courage, in performing what they believed to be their duty are we mainly indebted for the introducwe sd: te vorend en |