THE RELATION OF SURGERY TO GYNAECOLOGY


THE RELATION OF SURGERY TO GYNAECOLOGY. SOME years ago there appeared in Madison Square, New York City, a colossal hand; neither its functions nor relationship was readily discerned. It projected above the greensward as though some mighty Titan had been poorly buried, or as though some mythical creature were again emerging from the dreamless sleep of an ancient sculpture. Though bared to the wrist only, it towered high above the head of the observer who gazed with awesome curiosity upon this emblem of marvelous skill and power and wondered at its significance.


SOME years ago there appeared in Madison Square, New York City, a colossal hand; neither its functions nor relationship was readily discerned. It projected above the greensward as though some mighty Titan had been poorly buried, or as though some mythical creature were again emerging from the dreamless sleep of an ancient sculpture. Though bared to the wrist only, it towered high above the head of the observer who gazed with awesome curiosity upon this emblem of marvelous skill and power and wondered at its significance. It was the hand of Bartholdi’s Goddess, destined to light a universe.

Years passed, and across the water the body of this famous goddess was assuming form under the deft direction of its originator. When the hand was next seen it had abandoned its long divorcement and appeared as the crowing glory of the statue, piercing the blue ether far above its Parisian surroundings, and ready to again across the ocean, leading the fair goddess to her permanent home, where she should stand beneath the effulgence of its radiant torch. There she stands to day, personifying “Liberty enlightening the world”.

The relation of surgery to gynaecology is not unlike that of the torch-bearing hand to the goddess of Bartholdi, which symbolizes the upward and onward progress of art, and illuminates not only itself, but also all that comes within its influence. So surgery symbolizes the growth of medical art, illumines the entire gynaecological structure, and throws its light upon the whole world of medical science.

What has surgery done and what is it doing to merit so great an encomium? It has turned, and is turning, doubt into certainty, ignorance into knowledge, insecurity into safety.

Gynaecology was but a stumbling and a halting child before the strong hand of surgery led its wavering footsteps firmly by the pitfalls of uncertainty and developed its unsteady gait into the sturdy pace of athletic progress.

For the purposes of this paper we take gynaecology to mean that branch of medical science which pertains to the anatomy and physiology of the special organs of generation and their immediate surroundings-the aetiology, pathology and management of their diseases. As the management of gynaecological cases must be either surgical or non-surgical, we take the term surgery to mean that science which develops the principle of mechanical and operative procedures for the relief of any disease and determines the principles of their application.

It is not the intention to institute invidious comparisons between operative and non-operative methods of treatment; for they are so intimately joined, and their objects so identical, that they must ever be considered as forming a union whose unity of purpose is its strongest bond, but still it may not be unprofitable to pass in review the achievements of surgery which have brought fame to gynaecology.

The progress of gynaecology during the last twenty-five years is marvelous, but rendered so by the triumphant march of surgery, which, like a veritable Moses has led and is still leading the gynaecological hosts up out of the wilderness of crudity. The scalpel in living tissue is the open sesame which unlocks both pathological and functional mysteries and brings nearer to our grasp the very secret of life itself.

Before passing to the consideration of specific performance let us emphasize the fact that in antisepsis, or the more refined asepsis, we have the foundation for the brilliant surgical exploits of which we are so justly proud. The renown of surgery no longer depends upon the glamour of exceptional success, but upon that uniformity of result which must ever follow the recognition and application of universal principles.

Primitive surgery and modern surgery do not differ alone in the application of the principles of antisepsis, but in the development of principles which govern the process of repair and the recognition of pathological methods and new insight into physiological function. Primitive surgery was, of necessity, external surgery and experimental. The auto-amputation of extremities and to initiative surgical procedure. Modern surgery, and especially gynecian surgery, is internal surgery and demonstrative, and marks the highest degree of adaptation of principles deduced from external work. The so-called citadels of life are no longer defended against operative attack, yet here, as in primitive surgery, we work upon the periphery.

Accidental surgery has been the precursor of deliberative imitation, the tamping-rod emphasized the use of the trephine, and the ripping horn of the infuriated animal, whilst it led us to fear the bull more, has certainly caused us to dread the peritoneum less. Two cavities were thus opened whose viscera are now daily attacked by the knight of the bistoury.

Primitive abdominal surgery was first confined to the repair of accidental injuries. When the intestines protruded through a wound in the abdominal wall, the prudent surgeon cleansed the bowels and replaced them, sewed up the rent, and gave his patient rest; a rest which was not always the one which knows no waking. When the intestines were wounded, however, long and patient study was required before modern surgery evolved the rule which not only justifies but commands the immediate laparotomy which furnishes exact scrutiny of the parts injured, and an opportunity for the application of exact operative methods.

In this, gynaecology has been the gainer. The operative problems which have been presented to the gynaecologist, have, many times, been solved n advance through the development of surgical truths and principles which are found to be the most valuable when the most general in their application.

When the harassed gynaecologist of the non-operative type has exhausted all the resources of mechanical and medicinal methods in the vain endeavor to restore a retroverted uterus, and asks of surgery for assistance, the answer comes unhestitatingly-open the abdomen, release the adhesions, and anchor the uterus to the abdominal wall; or, after the method of the Alguie-Alexander-Adams operation, take a reef in the round ligaments.

Are the ovaries and tubes caught within the octopus grasp of a pelvic inflammation, and deprived of their liberty of action, the appendages are removed, and the patient relieved at least of one great source of irritation or nerve waste. Do they develop a cyst whose ever increasing pressure not only imperils the comfort but the very life of the patient; surgery leads the gynaecologist to remove the cyst as soon as discovered, and not to till further jeopardize the patient by inane assaults of the aspirating! Does a persistent intra-metritic haemorrhage drain the vitality and resist the “indicated remedy.” surgery curettes that uterus, clearing it of placental debris or granular proliferations; the devastating current is stayed and damage soon repaired.

Has a cervix or perinaeum yielded to the force of a parturient assault, surgery restores their autonomy; saving the patient on the one hand from a cancer-breeding nidus, and on the other hand from a displacement-courting impairment.

Do fistulae deflect the natural course of rectal and bladder contents, the surgeon’s skill repairs the openings and the excretory channels resume their normal functions. Dose vesical wall or rectal pouch encroach on vaginal space, the surgeon, with the skill of a modiste, takes a tuck in the redundant tissue and each viscus is restored.

Does the study gonococcus, ambitions to conquer new territory, invade the secluded precincts of the Fallopian tube, and there multiply and replenish its pus until the confines of its operations, sell to dangerous proportions, surgery again rescues the patient, and puts those tubes where the coccus must cease from troubling, and menstruation takes a rest.

Does the erratic myoma explore peritoneal space, or, seek the outer world through polypoid transmigration, or, stay at home and enjoy its intra-mural development, it falls a prey to the surgical poacher, who does not hesitate to remove, not only the game, but the very preserves in which it abounds.

Does that great enemy of womankind, the cancer, attack with all its malignity the primitive home of foetal nativity, and seek to overthrow with inevitable encroachment the temple dedicated to the cause of maternity, the alert gynaecologist knows that the only hope of rescue lies in a total surgical ablation. Medicine has not yet furnished the remedy, and surgery, at best, furnishes only a possible reprieve.

Does pelvic inflammation run riot in the delicate tissues which form the uterine surroundings, and, by the violence of its assault, melt all before it in the fury of a purulent conflagration, the early relief of the surgeon’s knife furnishes the speediest means of staying its ravages, and supplements, with potent co-operation, all therapeutic endeavor.

Does pain, with continuous grasp, wring from the chronic sufferer the imperative cry for help, and surgery, with deft skill, remove the innocent appendages and leave the pain behind, gynaecology has even then been a gainer, and diagnostic acumen receives a new impetus and finds in the uterine cavity the hitherto unsuspected pathology.

Does gynecian physiology look to the ovaries for the explanation of menstrual phenomena, and call upon surgery to remove them, in the vain hope of preventing the periodic flux, it finds that the unsacrificed tubes have a function which has certainly been overlooked.

Does the wily tumor, with almost sentient perverseness, defy diagnostic skill, the scalpel lets in the search-light of observation, and the wandering kidney, the cystic kidney, the hydro-nephritic cyst, the renal calculus, the mesenteric sarcoma, the tubercular agglutination, the lithopedion, the stay-liver, the malarial spleen, the pancreatic cancer, are all revealed, and a prognostic prediction saved from a diagnostic defeat.

Does the question arise whether autonomy depends upon uterine persistence, the hysterectomy determines that ovarian life is a separate life, and exists just as certainly as the human face after the mirror which reflected it is shattered.

Does a tuberculous peritonitis invade the abdominal cavity, thickening the delicate lining of that enormous lymph sac, studding intestinal wall and swelling mesenteric glands, surgery gives gynaecology another triumph, and, by its exploratory incision, changes the whole aspect of affairs-a pathological miracle is wrought, and the grave literally robbed of its victim.

But enough! Why multiply examples? Modern gynaecology is a splendid structure, but the hand that holds the torch is the hand that holds the knife.

DISCUSSION.

H.E. BEEBE, M.D.: The subject is certainly one which has been well handled, and I gladly admit my incapacity to add to or justly criticise the paper of my friend Dr. Walton.

To my candid observer it must be plain that progress is stamped upon the doings of everything closing the scenes of the nineteenth century, whatever be the department.

Effective work in all branches of science and art is the basis of success. Specialist are ever in demand.

Positive specific results muse be attained to merit worthy commendation. To-day “fads” are short lived; the twentieth century is to be inaugurated with fewer shams. Perfection is the goal in view.

Surgery is not an exception, and it is impossible to ignore the prominence which gynaecological surgery has everywhere assumed. It is called to accomplish what non-surgical agencies have failed to do-mechanically correct false physiology and pathology.

Abnormalities are to be ameliorated, and cured, if possible, and that too by the most conservative measures. The may be by simple methods or the most expert work.

Effective surgery depends upon knowing when to use it, skill and thoroughness in its performance and efficient after- treatment. Many surgeons are good operators, but are careless in the subsequent attention. To avoid infecting the wound is as important as brilliant operating.

Surgical diseases of women are no small part of the gynaecologist’s practice. Of morbid growths alone, both malignant and benign, affecting the human race, more than 75 per cent. belong to the female organs of generation and are either uterine, ovarian or mammary.

With this fact, and knowing that morbid growths are but a small part of the surgical diseases of women, certainly there is a broad field for surgery in this speciality.

About one-third of all physicians claim to be gynaecologists. To fully ninety-nine-hundredths of this number the teachings of diseases of women have not been thorough and practical. The average gynaecological specialist is capable of doing many of the simpler operations through the natural passages, but it is a great mistake for amateurs who have never done major surgery to attempt operations through artificial openings involving the peritoneum, such as are considered in this paper.

The surgical novices have no business doing this internal major surgery. Few gynaecologists are trained abdominal surgeons; they have not spent enough time in the study of visceral anatomy in the dead-house, nor been in the clinical fields, eye-witnesses “to the scalped to living tissue” by experienced operators. Training and experienced observation are very necessary for so important a work.

To depend upon self-experience alone to learn major surgical gynaecology at the patient’s risk is a responsible matter. Abdominal surgery is a specialty within itself, and needs as much preparation as any specialty.

There are too many laparotomies done and too many untrained operators are doing them to the great detriment of justifiable work. The surgeons lacks acquired knowledge and skill, besides the facilities for doing good work. Seldom, except in emergency, is laparotomy warrantable without a room thoroughly prepared for it.

Skilled abdominal surgeons to-day have a uniform mortality of only about 10 per cent., and a per cent. greater then this usually means incompetency.

The advance made in the field, and so well shown in the paper, has been by experts well trained in antisepsis and the anatomy, physiology and pathology of the female organs of generation.

They knew what to do, when to do it, and how to do it. They knew “the relation of surgery to gynaecology,” and that “the hand that holds the torch is the hand that holds the knife.” .

DR. HANCHETT, of Omaha: I am not here to criticise this noble paper which has been read, but to say “amen” most heartily to it. I make no claim to being a gynaecologist. I treat some cases in my office, as all physicians in general practice, do but I want to say to every general practitioners here that when we have a case of operative surgery in the line of gynaecology we should sent it to a specialist. I have seen in my own city, and many of the western cities of this country, many a life lost by foolish operative surgery on the part of so called gynaecologists who did not understand their business.

Mr. AYERS, M.D., of Rushville, Illinois: I live in a little country town, and we have a few patients of the kind referred to by the last speaker. Ninety-nine out of a hundred of them haven’t got money enough to get out of town. What are you going to do about it? I say do the work the best you can.

PHOERE J.B. WAITE, M.D.: I have enjoyed the paper most heartily. I am frequently in the habit of passing down the bay in New York and observing Liberty enlightening the world-a beautiful statue, to be sure-and I admire the application made in the paper. However much I may admire surgery, I would make the plea for medical treatment in gynaecological practice. The surgeon has come to be prominent in gynaecological practice, and surgeons and physicians are too fond or using the knife. I have seen too many young women, who, have passed under the surgeons knife from whom the ovaries have been removed single women and married women who in my opinion, might have been spared this infliction, because it is a very great infliction.

I have in mind a beautiful young wife who came to me about nine months ago in a very despondent frame of mind, very much distressed over a diagnosis which had been made in her case, and had been told there was no help for her except in the removal of the ovaries. Said I : “You are a stranger to me, but if you were my daughter I would as soon you had your head cut off as to have your ovaries removed.”

She consented to give up the operation and placed herself in my hands. She had been told that she could have no more children, and she was very anxious to become a mother. I took the case, and three months ago she came to me looking bright and happy, and informed me that she was three months pregnant. So much for taking hold o a case medically.

I have also in my mind a young unmarried woman who suffered from dysmenorrhoea, and she passed under this skilled surgeon’s hands; the ovaries were removed, and she did not get better. She grew worse, and to-day she is hopelessly insane. I believe she might have been cured if the Homoeopathic remedies had been carefully studied in her case.

While, as I say, I have great respect for surgery, I have still greater respect for medical treatment.

MARTHA J. RIPLEY, M.D.: I wish to emphasize the remarks made by the last speaker. While agreeing with the very able paper in cases of dire necessity, I should not be true t my convictions as a physician and as a woman if I did not say call a halt on your operations upon women. It is high time that you did so, because to-day many a woman is being operated on in all of our large cities, and in some of our small ones, who needs no operation at all. I could recall case after case of women who are to-day in insane asylums.

My dearest friend went to her grave a week ago from an operation by a skilled gynaecologist. Those operations needed, but beware how you practice them upon women who do not need them. Practice and study your Materia Medica. It is well that some of you do live in small towns where you cannot get skilled surgeons, or I fear there would be very few of your women patients left.

Now, I am looking in the faces of young men who come here and listen to the words of the older surgeons, and I recall what a student of my own said. He came to me and said he was going to perform what I considered quite a difficult operation on a lady. I said to him, “Well, I have got to learn some time, why shouldn’t I begin now?” If you have got to learn upon women, go where those who are your teachers can teach you.

You understand that I believe there are operations that are needed, and then needed they should be promptly done, and you that have patients that are beyond your skill send them to those that you think can do better; but I call a halt upon operations upon women that are being done to-day. Turn to your own sex and see if they don’t need it, too.

ALONZO BOOTHBY, M.D.: I did not propose to say anything upon Dr. Walton’s paper, but it has been criticized in such a spirit that I feel called upon to say a word. I do not believe that my brother Walton intended in any way to convey the idea that unnecessary and improper operations should be made. It is not the skilled surgeon nor the skilled gynaecologist that operators when he ought not to. It is in those cases where there is a diseased ovary or a diseased tube that is beyond curative measures.

You know it as well as I do. Every physician that has ever opened the abdominal cavity knows it, and when you come to the statistics there is not ten percent, of fatalities. I would speak very modestly for myself, and say that if three cases that were operated on before I came here shall recover, it will make 102 (in the Homoeopathic hospital and my own institution) successful cases, and that includes 12 or 15 hysterectomies and 6 cases of appendicitis, and the various other cases that come up. When we can do this and have these results it is entirely out of place to assume that we are removing a woman’s ovaries when we would not do the same thing to a man.

H.W. ROBY, M.D.: of Topeka: In all medical conventions that I have ever attended I have heard similar discussion to this, and I believe their necessity grows out of the fact that some minds are organized in one direction and some in another. Some men and some women in the practice of medicine give their time and their study and thought along the lines of Materia Medica and therapeutics; others, of surgery, gynaecology, and so on, and each become enthusiastic in their line and in their specialities, and very often overlook the powers and capacities of the other field of practice.

The thing that we need is, to know so much about surgical capacity, and medical capacity, and therapeutic capacity that we shall be able to make a wise and just discrimination, and use medicines where medicines are efficient, and where they are inefficient to resort to that which is efficient. I have seen, and you have seen many a time, patients subjected to medical treatment day after day, week after week, and month after month, through long and weary years, without result, who, if they had been handed over to a skilful surgeon, a slight operation might have set him on the pedestal of life and happiness. I plead here for a just discrimination between medical and surgical cases. They are both useful in their place.

Homoeopathy has a grand field in which it may be successful, but outside of that field there are other possibilities, other capacities, and other powers. if you have given time and attention to medical practice do not be too sure that that is all there is within our command for the relief of suffering humanity.

Charles E Walton