CLINICAL CONTRIBUTION TO THE SUBJECT OF REMOVAL OF THE UTERUS IN WHOLE OR IN PART FOR THE EXTIRPATION OF TUMORS CONNECTED WITH THAT ORGAN.

By T. GAILLARD THOMAS, M.D.,

NEW YORK.

THE exigencies of modern surgery are very great; and instead of diminishing in number as unexplored fields are invaded and fresh positions conquered, they appear to develop new propor tions. In our day we have seen paracentesis of the gall-bladder, the membranes of the brain and the pericardium; extirpation of the larynx and rectum; and ablation of the kidney and spleen, placed upon enduring bases as operative procedures; and gradually even the most conservative are yielding to the conviction that it has become essential that the uterus should be rendered amenable to complete removal.

There are three circumstances under which complete extirpation of the uterus may now be regarded as a legitimate and often a necessary procedure: first, where it is, after Freund's method, removed on account of malignant disease; second, where, as an addendum to the Cæsarean section, it is practised after Porro's plan; and third, where it is extirpated to render practicable the removal of tumors, either of solid or cystic character, which take their origin in its tissues, or, arising in the ovaries, form attachments to it too firm to be broken.

It is with the third and last of these indications that I propose to deal to-day.

I have said that the most conservative must gradually yield to the demand of modern surgery for the removal of the entire uterus by laparotomy; it is in this class of cases that they must first do so. It should not, however, be supposed that even here a conservatism, the honesty of which we must all respect, although sometimes boldly dissenting from its deductions, has yet been VOL. XXXI.-38

fully satisfied. That this is by no means the case the following quotations from some of our best authorities will prove.

Barnes, writing so lately as two years ago, declares that "the time has not yet come for forming a confident opinion upon the practice of laparotomy for the removal of uterine fibroids, either alone or with the uterus. At present there is little ground for enthusiastic advocacy of the practice. The case may best be summed up by stating that the question is ad hoc sub judice. We must for a while be content with the divided opinions expressed in the Academy of Medicine on the occasion of a report presented by Demarquay on memoirs by Koeberlé, who advocates the proceeding, and by Boinet, who condemns it. Boinet showed that the operation had for the most part been performed accidentally in cases mistaken for enlarged ovary; that it could not be defended on the same grounds as ovariotomy; that it should always be rejected when the tumor was not pedunculated, and especially when it involves the entire or partial removal of the uterus. Demarquay agreed with Boinet. On the other hand, Richet cautioned the Academy against pronouncing any summary condemnation of an operation which at present is dreaded as ovariotomy once was." For myself, let me say that it is truly a sad spectacle for the world of surgery to behold the Academy of Medicine of Paris, the great deeds of whose founders have in times past electrified their contemporaries by their originality and brilliancy, to-day restrained by the warning voice of one man, Richet, from condemning a procedure which is as sure to be demanded by the surgery of the future as ovariotomy was by that of the past!

Emmet, in the second edition of a treatise upon gynæcology, of which all his countrymen feel justly proud, says: "To remove the uterus when enormously enlarged from a fibrous growth, is unquestionably one of the most formidable operations a surgeon can be called upon to undertake. The degree of success which has so far attended the operation offers but little encouragement for the future. M. Péan, of Paris, presented, in 1873, seven recoveries out of nine cases where he removed the uterus for fibrous growths. As this success has not been equalled by any other operator, we must suppose it to have been accidental, and that subsequently he himself has not been so fortunate, as already six years have elapsed since his last report."

I could go on quoting to this effect for any length of time,

but I lack incentive to do so; all my hearers know that the prevailing opinion goes with the eminent authors whom I have just quoted, and that I am to-day giving evidence in favor of a young and feeble cause.

An honest conservatism is the bulwark of scientific surgery, but there is no virtue so likely to run to dangerous extremes as this very one whose merits we are lauding. Let us remember how many life-saving procedures have been condemned in times past which to-day command our highest esteem, and let us be cautious how in a laudable effort to avoid recklessness, we repeat the errors of our forefathers in attempting to suppress what time has now, set its seal upon as valuable contributions to our art. Fifty years ago the operation of laparotomy for the removal of ovarian cysts was almost universally condemned as a surgical temerity for which it was very questionable whether the perpetrators ought not to be held amenable to the law. No epithets were regarded as too vile to be hurled as anathemas against the men who were regarded as so reckless as to peril human life by its performance, and it required a good deal of moral courage for one to be willing even to sanction by his presence a procedure about the surgical impropriety of which there was so unanimous a verdict. And let us not forget that results seemed for a long time to uphold the view of the majority. Many died of those operated upon, and few recovered; women suffering from obesity, tympanites, or pregnancy were, through errors of diagnosis, exposed to the great and uncalled for dangers of laparotomy; and even in simple cases intestines were torn, large blood vessels severed, or sponges and instruments sewed up in the devoted. bodies of the victims of reckless surgery often enough to give powerful arguments to the opposition.

Fifty years have passed away, and what is now the position of this "opprobrium chirurgia?" What the fate of the men who bore in its infancy the ignominy of sustaining it? McDowell, its discoverer, has just had a monument erected to his honored memory, and the names of Atlee, Peaslee, Wells, Keith, Koeberlé, Dunlap, and Kimball stand high in the annals of surgery. It has become rather a favorite mathematical exploit for anniversary orators to calculate how many centuries of life have been given to woman by the establishment of the operation of ovariotomy upon an enduring basis. We learn of twenty, thirty, forty, seventy successive operations without a single death; and

we hear one of the most eminent of ovariotomists declaring it to be "the safest of all the great surgical operations!"

It is with the desire to put upon record further testimony from which may be drawn reliable deductions as to the propriety of removing solid or cystic tumors by laparotomy, when such removal involves the necessity of ablation of the uterus, that this clinical contribution is made.

CASE I.-Dora G., single, aged forty-three, entered the Woman's Hospital in May, 1874. Six years previous to that time she had noticed an abdominal enlargement, which went on steadily increasing for three years, when she was told by a physician that it was a solid tumor of the womb. Two years before admission she was attacked by severe pain, which, from her description, was probably due to peritonitis. At the time of admission the patient was found to be very much emaciated, and the abdomen large and hard. She suffered greatly from constipation and from frequent micturition, and could sleep only in the sitting posture. The respiration was eighteen to the minute, pulse ninety-two, and large veins were found on the surface of the abdomen. The uterus could not be touched upon digital examination. The largest circumference of the abdomen was found to be fifty-two inches; measurement from pubes to umbilicus fourteen inches, and from ensiform cartilage to umbilicus thirteen inches.

The diagnosis of large fibrous tumor of the uterus was made, and upon consultation with Drs. Peaslee, Emmet, Metcalfe, Markoe, and Peters, operation was decided upon, and performed on the 18th of May.

An incision four inches in length was made from the pubes upwards, and the hand being introduced, the tumor was found every where adherent to the abdominal walls and intestines, which were firmly attached to its lateral and upper surfaces. The incision was now extended upwards, the adhesions broken, many vessels tied, and the tumor lifted from its position in the abdomen by two assistants. A temporary clamp was applied at the very lowest portion of the cervix, ligatures passed below it at right angles to each other, the pedicle securely tied, the clamp removed, and the stump kept between the lips of the wound by a long knitting-needle. A drainage tube was then introduced, the wound closed by silver suture, and the patient put to bed and quieted by opium.